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Ruth Dulin
Office: 866-533-5899
Fax: 888-818-9113
Email:
Ruth@PEDS-Exclusively.com
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Candidate Questionnaire
Is Confidential
Personal Information
First Name
Last Name
Postfix (Select all that apply)
DDS
DMD
MD
Address
City
State
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip
Home Phone
Work Phone
Mobile Phone
Pager
Preferred Number
Home
Cell
Work
Pager
Email Address
Best time to contact you?
Morning
Afternoon
Evening
Night
Tell Us About Yourself
Marital Status
Engaged
Divorced
Married
Other
Single
Widowed
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)
Business Manager
Endodontist
General Dentist
Oral Surgeon
Orthodontist
Pediatric Dentist
Periodontist
Prosthodontist
Fellow Training (please list your training and program of training)
Current Status
Current Status (Select all that apply)
Actively Practicing
Board Certified
Board Eligible
Confidential
Fellow
Independent Contract
Military (active)
Military (past)
Not Practicing
Resident
Retired
US Citizen
Visa Status
Resident Graduate?
Year
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
Military Separating
Year
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
Preferred Situation
Preferred Situation (Select all that apply)
Active Military seeking Part Time
Associate
Associate to Partnership
Contract Work
Employed
Full Time
Health/Illness Transitions
Hospital
Independent Contract
Locum
Other
Part Time
Purchase a Practice
Retirement Transition Practice 1 to 5 years
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)
Anesthesia Certified
Board Eligible
Board Certified
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)
CITA
CRDTS
NERB
SERTA
WREB
Malpractice History
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?
Have you ever been convicted of a felony?
*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?
Yes
No
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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