| PERSONAL
INFORMATION |
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| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Pager: |
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| Email: |
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|
PROFILE |
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| Specialty: |
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| Sub Specialty: |
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| Visa
Status: |
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| Date Available: |
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| Geographic
Preference #1: |
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| Geographic
Preference #2: |
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| Geographic
Preference #3: |
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| Size
Community Desired: |
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| Where do you
have family ties?: |
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| Would you
like to relocate near family
ties: |
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| Where is
your hometown?: |
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| Do you have
any special family
needs: |
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| What type of
practice are you
seeking: |
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| Where are
you licensed or where have you
applied for a
license: |
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| What are you
salary
expectations: |
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| Do you have
any outstanding
loans: |
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| Are you
looking for a position with
federal/state loan
repayment: |
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| What is your
call schedule
preference: |
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| Are there
any special medical skills you
would like to make us aware
of: |
|
| If married,
does your spouse need any
assistence with
employment: |
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| If you have
children, what type of schools
are you looking to put your
kids into: |
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| What are you
hobbies and
interests: |
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| Date of
board elegibility? Date of
board
certification?: |
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| What dates
do you have available to
interview? Please indicate if
you will be visiting family,
interviewing, or vacationing
anywhere in the near future
near any of the areas you are
targeting
geographically: |
|
| If
practicing, why are you leaving
your current
position?: |
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| Have you
completed all three steps of
the USMLE's? Indicate if you
have passed all steps on the
first try and if you have
completed all three steps
within 7 years: |
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| Any
additional information that you
want to give us to help with
your job search: |
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