PHYSICIAN/APPLICANT QUESTIONAIRE

DOC ON THE WEB

To take advantage of the innovations in physician recruitment which TRAPANI & ASSOCIATES offers, complete and return the enrollment form below. Please note your information will be treated with complete confidentiality and will not be released to anyone until we have discussed the matter with you and have your permission.

We look forward to hearing from you soon. If you have any questions, please call or EMAIL US. The number is (800)755-9725.

NAME:
MAILING ADDRESS:
Address line 2:
City, State, Postal Code:
Office phone:		Best time to call:
Home phone:		Best time to call:
E-mail address:

Specialty(ies) under which you wish to be listed:

I would like to continue receiving Trapani & Associates' Physician's Career Opportunity Quarterly:
Yes / No

Practice Characteristics:

Please check practice characteristics you will consider.
Mark "no" for options you will absolutely not consider.

	Yes	No
Solo:
Partner:
Hospital:
Multi-Specialty Group:
Single Specialty Group:
HMO/Clinic:

Patient Mix

Outpatient only
Inpatient / Oupatient Mix

Cross coverage requirements:

Geographic preferences: Please indicate your 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.

	Preferred	OK	NO
less than 20,000:
20,000 - 50,000:
50,000 - 100,000:
100,000 - 250,000:
250,000 or more:

Special community characteristics requested:

PHYSICIAN TRAINING

Medical School:

Internship(s):

Residency(ies):

Fellowship(s):

When would you be available
to begin working?

Will your spouse be seeking employment? Yes / No

If yes, in what field(s)?

Special interests/hobbies:

Other criteria:

Code #s for practices of interest
to you listed in the enclosed Quarterly:

Click here to erase all answers and start over:

OK, Doc on the Web, here's all my data, take it and run with it!

PLEASE FEEL FREE TO COPY THIS PHYSICIAN QUESTIONNAIRE FOR YOUR COLLEAGUES WHO MAY BE INTERESTED IN RECEIVING OUR PHYSICIAN'S CAREER OPPORTUNITY QUARTERLY

GO TO PHYSICIAN PRACTICE OPPORTUNITIES MENU

RETURN TO MAIN MENU

FOR MORE INFORMATION ABOUT OUR SERVICES, OR TO REVIEW

OUR PRACTICE OPPORTUNITY DATABASE AT YOUR

CONVENIENCE, PLEASE FEEL FREE TO ACCESS

DOC ON THE WEB

THROUGH THE WORLD WIDE WEB

www.webdoc.com
EMAIL US

or call us @ 800-755-9725

Medical School:
Internship(s):
Residency(ies):
Fellowship(s):
When would you be available to begin working?
Will your spouse be seeking employment?	Yes / No
If yes, in what field(s)?
Special interests/hobbies:
Other criteria:
Code #s for practices of interest to you listed in the enclosed Quarterly: