Name :
Email :
Address :
City :
State :
Postal Code :
Office Phone :	Best time to call :
Home Phone :	Best time to call :
Specialty(ies) under which you wish to be listed :
Practice Characteristics:
Please check practice characteristics you will consider. Mark "no" for options you will absolutely not consider.
Solo:	Yes / No
Partner:	Yes / No
Hospital:	Yes / No
Multi-Specialty Group:	Yes / No
Single-Specialty Group:	Yes / No
HMO/Clinic:	Yes / No
Patient Mix:	Yes / No
Cross coverage requirements:	None required With 1 With 2 With 3 With 4 or more
Geographic preferences:	Select preferred locations AL AR AZ CA CO CT DC DE FL GA IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Priority cities:
Community Size:
Please check community sizes you will consider. Mark "no" for options you will absolutely not consider
less than 20,000:	Preferred / Yes / No
20,000 - 50,000:	Preferred / Yes / No
50,000 - 100,000:	Preferred / Yes / No
100,000 - 250,000:	Preferred / Yes / No
250,000 or more:	Preferred / Yes / No
Special community characteristics:
PHYSICIAN TRAINING
Medical School:
Residency(ies):
Fellowship(s):
When would you be available to begin working?
Other criteria:
Attached your CV :

Please note all information will be treated with complete confidentiality and will not be released until we have discussed the matter personally with you and receive your permission.

We look forward to hearing from you soon. If you have any questions, please contact us at 1-800-438-2476 or mail us at sternd@danielstern.com.