Intern IT Sheet

IT Sheet Intern

Online Form for IT Purposes

Name*
First Middle Initial Last
Date of Birth*
MM slash DD slash YYYY
SSN*
Gender*
- Male
- Female
Start Date*
MM slash DD slash YYYY
Organization*
Site
Program
Other
County
- Thomas
- Grady
- Colquitt
- Mitchell
- Decatur
- Seminole
Check All that Apply, please.
Immediate (Clinical) Supervisor
2nd Level Manager
Job Title
Is this a Para Pro Position*
- No
- Yes
Education Completed*
Major
Are you professionally licensed or certified?*
- No
- Yes
If not, are you working towards a license/certification?
If Yes, what type:
License
NPI
DEA Permit
Password for Company Email*

This is a password for a company Email Account. Minimum of 8 Characters and must combine at least three of the following: uppercase letters, lowercase letters, numbers and symbols. You cannot use your full first name, last name, first initial and last name, etc.

Contact info

If you are experiencing a medical emergency, please call 911. If you are experiencing a Mental Health crisis, please phone the Crisis Center at 229-225-3917 or go to the Crisis Center at 525 Cassidy Road in Thomasville, Georgia.

If you need to set up an appointment or medication refill, please call during our regular business hours between 8:00am and 5:00pm or leave a message and someone will contact you when the offices are open.