Public Health Professional Contractor Registration

Please complete the following registration form. Once registered, we will review your submission and contact you via email. For questions, email Arielle@ohiopha.org

Name*

First Last

Primary Email*

Secondary Email

We recommend providing at least one personal email address in case your place of employment changes.

Phone*

Address*

Street Address City State Zip Code / Postal Code

Your address is used to match you with opportunities closest to your residence.

Please Upload Resume or Curriculum Vitae Here*

Accepted file types: jpg, pdf, png, doc, docx, xls, xlsx, ppt, Max. file size: 256 MB.

Allowed extensions: jpg,pdf,png,doc,docx,xls,xlsx,ppt

Maximum number of hours available per week*

Select approximate number of hours available. For each assignment, we will check with you on your availability to see if it has changed.

Please provide your general availability*

Business Hours
Evenings
Weekends

Check all that apply. This can be approximate. We will check with you when a potential assignment is identified to see if your availability has changed.

Comments Regarding your Availability

Please provide your academic degrees licenses*

Associates
Bachelor's
Master's
Doctorate
Other

Check all that apply

Please select your professional licenses:

Check all that apply

If other Professional Licenses, please specify:

Please select your professional skillsets/experience:*

Please select skill in which you consider yourself to have intermediate to advanced knowledge.

If other Professional Skillsets, please specify:

Please select your topic specialties:*

Please select specialties in which you consider yourself to have intermediate to advanced knowledge.

If other Professional Specialties, please specify:

General Comments/Additional Information

Public Health Professional Services Consultant Enrollment

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Questions?

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