Candidate Questionnaire

Is Confidential

Personal Information

First Name

Last Name

Postfix (Select all that apply)

Address

City

State

Zip

Home Phone

Work Phone

Mobile Phone

Pager

Preferred Number

Email Address

Best time to contact you?

Tell Us About Yourself

Marital Status
Spouse's Name	Spouse's Occupation
Children/Ages
Your Home Town	Spouse's Home Town
US Citizen	*If no, Visa status
Hobbies or special interest
Any special family needs or disabilities we should be aware of
Other information you would like to share

Profession

Profession (please select your current profession)
Fellow Training (please list your training and program of training)

Current Status

Current Status (Select all that apply)

Resident Graduate?

Year

Military Separating

Year

Preferred Situation

Preferred Situation (Select all that apply)

Preferred Locations

1st Choice	2nd Choice
3rd Choice	4th Choice
Would your spouse agree with you on these locations?

Professional Information

Certifications (Select all that apply)
College/undergrad	Completed (M/D/Y)
Dental School	Completed
Internship	Completed (M/D/Y)
Internship	Completed
Medical School	Completed (M/D/Y)
Residency	Completed
Fellowship	Completed (M/D/Y)
Fellowship specialty of training and Program
Licensure in what state(s)
What state(s) will you be applying for?

Regional Boards

Regional Boards (Select all that apply)

Malpractice History

Have you ever been convicted of a felony?

Have you ever been named in a malpractice suite?

Have you ever had a license suspended or revoked or limited?

Have you ever had your hospital privileges suspended or revoked?

Have you ever been treated for drugs or alcohol abuse?

*If yes to above questions, please explain and attach any documents if needed

General Questions

If you completed a fellowship, is it important to practice this scope of practice?

Would you prefer to practice in a metro or rural location? (if rural how far to metro)

What opportunities have you already contacted? (be specific so we do not contact them)

If you are leaving a practice, please explain departure reasons

Practice philosophy

Preferred scope of practice

Preferred call schedule

Is a computerized office important to you?

Describe your personality in the office environment

Acceptable years to full partnership

Describe your ideal work environment (staff, number of partners, number of office locations, etc)

Compensation as an Associate (briefly define your ideal compensation package)

Compensations as a Partner (briefly define your ideal compensation package

Files

Attach CV

Attach Cover Letter

Attach Photo

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Candidate Questionnaire