Sterling Healthcare

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GENERAL INFORMATION

*First Name

*Last Name

Middle Name

*Title

Address
City	State	ZIP
Phone
Phone
Phone
Phone
Email Address:

Best time to contact

Prefer Contact By

		Month	Day	Year
Sex: Male Female	Date of Birth:
		City, State, Country
US Citizen: Yes No	Birthplace:

EDUCATION

Training: American Medical Graduate International Medical Graduate

Medical School:

Location (City, State, Country)

From:

Month

Day

Year

To:

Month

Day

Year

Specialty:	Status:	Certifying Board:

Sub-Specialty:	Status:

Residency Location (Facility, City, State, Country)

Practicing: Yes No

LICENSES

State:	Active	Inactive	Expired
State:	Active	Inactive	Expired
State:	Active	Inactive	Expired

OPPORTUNITY PREFERENCES

Interested in Opportunities for: (click all that apply)
Medical Directorship
Primary Staff Physicians (120 hours or more per month)
Supplemental Staff Physicians (less than 120 hours per month)
Allied Health Providers
Residents
Locum-Tenens

GEOGRAPHIC PREFERANCE

If you are interested in more than one location, please give us your top 3 state preferences in ranking order.
1.
2.
3.

Additional Comments:
(Ex: Preferred city, type of community, urban or rural setting, etc.)

How did you hear about Sterling Healthcare?

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			Flexibility as an Independent Contractor

			Competitive Compensation

			Support

			Comprehensive Professional Liability Insurance

			Customized Benefits

			Continuing Medical Education

			Medical Director Leadership Opportunities

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