ARSD 44:71:02:01. Application form and content

An application form provided by the department shall include the following: (1) Name and address of the employing facility; (2) Name and dated signature of a contact person; (3) Name and address of eligible health professional, plus any degree held; (4) Health professional's occupation and license or certification number; (5) Health professional's start date at the employing facility; and (6) Date when the vacancy filled by the health professional was created.