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Honea Path, SC

618-363-8247

FDP Medical Staffing / HireMedicalPros.com
Information Lead Sheet for Candidate Referrals
(revised 01-05)

Recruiting Agency: FDP Medical Staffing / HireMedicalPros.com
Recruiter's Name: Willie Jones
Recruiter's Phone Number: (618) 363-8247
Recruiter's Email Address: williej@hiremedicalpros.com

To submit your CV, please go to the Main Menu (on the left)
and email it to me at support@hiremedicalpros.com, or you
can email it to me at williej@hiremedicalpros.com.

Thank you.

Willie Jones

Candidate's First Name

Candidate's Last Name

Specialities

Email Address

Address

City

State

Zip Code

Office Phone Number

Home Phone Number

Cell Phone Number

Pager Number

Best Contact Number

Best time to call

Specific area the candidate is interested in? (List cities and states).

Why is the candidate interested in this particular area?

Is the candidate open to other areas? If so, where? (List cities and states).

What community size does the candidate prefer?

What type of practice does the candidate prefer? Solo, Group, Joint, Other?

Is the candidate willing to consider solo? Yes or No?

Is anyone else relocating with the candidate? If so, who?

Any particular family needs for the community?

Anyone else looking for a job opportunity? If so, who?

Was the candidate trained in a US medical school? Yes or No?

If NOT, where was the candidate trained?

If NOT, on a scale of 1-10, with 10 being exceptional, what are his/her English language skills?

If NOT, what US work authorization papers does the candidate have?

Is the candidate in a Residency or Fellowship program? If yes, program completion date?

What ACTIVE state license(s) does the candidate have?

Why does the candidate want to leave his/her current situation? Be specific and detailed.

Does the candidate wish this search be kept confidential? Yes or No?

When is the candidate available to begin his/her new practice?

Is the candidate board certified? Yes or No?

If not, when does he/she expect to become board certified?

Any history of malpractice suits, disciplinary actions, litigation, revoked license(s) or suspended hospital privileges? If so, please explain in detail.

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