ATTACHMENT A - Nebraska Department of Health and 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your last name, first name, middle initial, address, phone number, email address, and country of citizenship. Ensure all fields are filled accurately.
3. In the Professional Education section, list your educational background. Include the full names and addresses of your undergraduate college/university and medical school along with dates of attendance and graduation.
4. For Professional Training and Experience, provide details about your training institutions or organizations. Include dates of training and a brief description of your experience or specialty.
5. Complete the Medical Licensure section by listing all states where you hold a medical license or controlled substance number. If applicable, include your federal DEA number.
6. Answer the questions regarding any investigations or disciplinary actions against you. Attach explanations if necessary.
7. Fill in Current Employer Information if you are currently employed. Provide details about your employer and supervisor.
8. List references with their names, titles, addresses, and phone numbers in the References section.
9. Prepare your Personal Statement on a separate sheet as instructed and ensure to email it along with your CV to the provided address.
10. Finally, review the Agreement section carefully before signing and dating the application to confirm its accuracy.

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