Agency Registration Form



System login name consists of first name plus the last name’s first letter, if login name is taken then add the second letter from the last name.
Example: - if name is John Parish then login name will be johnp, if not available it will be johnpaSystem Password consist of 8 to 10 characters long, It could be numbers or letters or a mix of both( 1 number, 1 capital letter, 1 Small letter)
Example:- C3x9GPy
Type:
Position:
Gas Pin required:
Hire Date:
RadDatePicker
RadDatePicker
Open the calendar popup.
(mm/dd/yyyy)
First name:     Last name:     Login name:
   
    Must be between 8-10 char, [a..z][A..Z][0..9]
Care Plus Badge ID#: Must be 6 digits     Contact Phone #:
Personal Email (Requires by COPE and PFC Per Diems):
Department:
Select Department
    Location:
Select Location
    Supervisor:
Select Supervisor
Job Title:
Select Job Title
    Navigation:     Worker Role:
Select WorkerRole
NPI #:   NPI Effective Date:
RadDatePicker
RadDatePicker
Open the calendar popup.
   DEA License#:
I need access to:
Gender:
Choose the highest level of education/ degree:
Highest Education Level
If you are unlicensed, you can ignore these date fields
If you are a licensed clinician, License and Certification:
License And Certification
 
Effective Date:
RadDatePicker
RadDatePicker
Open the calendar popup.
Expiration Date :
RadDatePicker
RadDatePicker
Open the calendar popup.
Enter License#: 

If you have a 2nd licensed, License and Certification:
License And Certification
 
Effective Date:
RadDatePicker
RadDatePicker
Open the calendar popup.
Expiration Date :
RadDatePicker
RadDatePicker
Open the calendar popup.
Enter 2nd License#: 
Comment (optional)
RadEditor - HTML WYSIWYG Editor. MS Word-like content editing experience thanks to a rich set of formatting tools, dropdowns, dialogs, system modules and built-in spell-check.
RadEditor's components - toolbar, content area, modes and modules
   
Toolbar's wrapper  
Content area wrapper
RadEditor's bottom area: Design, Html and Preview modes, Statistics module and resize handle.
It contains RadEditor's Modes/views (HTML, Design and Preview), Statistics and Resizer
Editor Mode buttonsStatistics moduleEditor resizer
 
 
RadEditor's Modules - special tools used to provide extra information such as Tag Inspector, Real Time HTML Viewer, Tag Properties and other.
   
610 Valley Health Plaza, Paramus, New Jersey 07652 | Tel: 201.265.8200 | Fax: 201.265.0366 Designed by Isam Daifallah