Name*(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Email(Required) Signature(Required) By checking this box, I confirm that I received all applicable policies and education materials included in the initial application via email, as listed below. I also certify that the information on my application is correct to the best of my knowledge, and that the e-signature on the application is mine and mine alone. I agree to follow all hospital policies and Medical Staff Bylaws, and understand that I can find these online or by contacting Medical Staff Services. By submitting this form, I certify that I have reviewed all of the education requirements listed. I acknowledge that I have read the policies and materials pertaining to my credentialing and privileging with Hamilton Medical Center and that I will be held to these standards. I understand that this attestation will be stored in my credentialing file for future use.