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Name
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Street
Address
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City
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State
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Specialty
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Zip
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M.D. or
D.O.?
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Board Certified?
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States licensed
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Relocation
preference (States)
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Reason for
preferred states
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Community
Size Preference
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Situation
Preference (group, solo, etc.)
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Relocation
time frame
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Country of
Medical Degree
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Interest in ER work?
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Languages
spoken
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Citizenship
or visa status
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Marital
status/occupation
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Privileges or
license ever suspended, restricted or revoked?
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Children/Ages
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Hobbies/Interests
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How did you find this web site?
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Email
address
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Phone
Number
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Pager
Number
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Cell
Number
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Comments
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