BuiltWithNOF
Questionaire

Please answer the following questions regarding the type of practice you are seeking, size of community you would like to live in and any special needs you may have in finding the perfect practce opportunitiy. This information helps us get to know you better, and makes it easier for us to find the opportunity that best suits your needs.

Search Information Questionnaire

Name: Last_____________________First_______________________MI___

Address: Street:___________________________________Apt.No.__________

City_____________________ State_____________ Zip Code______

Phone: (work)_____________________(home)________________________

Specialty____________________Available(mo/yr)________________

Check board status: ______Board Certified ________Board Eligible

Practice type preferred: _____multi-specialty group _____single specialty group_____solo practice______ Partnership _____hospital-based practice______Other________________________________________ Licensed_______________________________________

Do you require any VISA sponsorship?______ If yes, what type?_______

Geographic areas of preference:

Region(s)__________________State(s) ________________

Cities (if applicable) ________________________________________________

Community size preferred (1000ís) ___10-50 ___50-100 __ 100-300 ___300+

Career considerations of spouse or significant other____________________________________________________

Special community needs or requirements (synagogue, special education programs, etc.)_____________________________________________

_______________________________________________________

Comments: ________________________________________________________

________________________________________________________

Please tell us about anyone else you know to whom we may be of assistance:
_________________________________________________________ _______

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