Emergency Healthcare Practitioners Volunteer Application
Section 1: Provider InformationFirst NameLast NameHome PhoneMobile PhoneEmailDate of BirthSection 2: Address InformationAddress Line 1Address Line 2CityState/ProvinceCounty of ResidenceZip CodeSection 3: License Information – List All States/OccupationsOccupation InformationHealth Professions OccupationProfessional License NumberIssuing StateOccupation InformationHealth Professions OccupationProfessional License NumberIssuing StateOccupation InformationHealth Professions OccupationProfessional License NumberIssuing StatePlease return application to: WAserv@doh.Internal Review Section for Department of HealthSection 3: Application ReviewDate the Registration receivedOccupation Professional StatusSignatureDate added to WAservLog-In Information AssignedOrganizationCOVID-19Facility AssignmentUser NamePasswordConfirm PasswordSecret QuestionSecret AnswerTerms of Service Checkbox ................
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