CPR: Provider Interview Form: Medical By answering the questions below Colorado Provider Recruitment can gain a better understanding of what you are looking for in a community and a practice. Sign up to work with CPR now!First Name* Last Name* Date Available* MM slash DD slash YYYY City* State* What is your state of origin? E-mail Address* Home or Cell Phone Number*Degree* CNM DDS DMD DO MD NP PA RDH ASN BSN Specialty* Certified Nurse Midwife Dental Hygienist Dentist Emergency Medicine Physician Family Nurse Practitioner Family Physician General Surgeon IM/Peds Internal Medicine Physician Medical Director OB/GYN Pediatrician Physician Assistant Psychiatrist Registered Nurse Medical/Graduate/Training School* City/State* Month/Year Graduated* Residency Program (if applicable) Residency City/State Residency - Month/Year Graduated Fellowship Program (if applicable) Fellowship - City/State Fellowship - Month/Year Graduated Board Status: Board Certified Board Eligible Will be eligible N/A If you are going to be eligible, please indicate what date: Licensed in what state(s):AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAre you interested in loan repayment? Current Position:* Student Resident or Fellow In practice Years of Experience Post Training Important Factors For Your Practice*Practice Preference: Inpatient, Outpatient, or Both I/P O/P Both Do You Require OB in Your Practice? Yes No No Preference Do You Require C-sections in Your Practice? Yes No No Preference Do You Have Prescriptive Authority? Yes No Will be eligible Please provide anticipated month/year you will have prescriptive authority: What are your salary requirements? Important factors in your selection of a location for you and your family*Preferred geographic area(s) in Colorado Please list all languages spoken: Residency Status* US H1-B J1 Permanent Resident Marital Status* Single Married Significant Other Will your spouse/significant other be seeking employment? Spouse/Significant Other's Occupation Number of children How did you hear about CPR? 3RNet Colorado Health Service Corps Loan Repayment Website Job Fair Online Job Board Professional Conference Residency/School Presentation Web Search Word of Mouth - Colleague/Friend Word of Mouth - Professional Organization Name of job fair, job board, conference, or word of mouth referral: Resume UploadMax. file size: 50 MB. Δ
By answering the questions below Colorado Provider Recruitment can gain a better understanding of what you are looking for in a community and a practice.
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