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Submit a Candidate Profile PLEASE FAX A COPY OF YOUR CV IF AVAILABLE (610) 431-4092       Name Specialty: Street Address Address (cont.) City State/Province Zip/Postal Code Home Phone Work Phone Beeper E-mail      Preferred State(s)  (in order of preference) 1.  2.   3. 4. 5. Home State     Medical School State Year of Graduation Internship State Year of Completion Residency State Year of Completion Fellowship State Year of Completion Board Status      Current Employment or  practice situation   Date available to begin practice     Preferred type of practice (in order of preference)   Solo   2 person partnership   Single Specialty Group (3 or more total)   Managed Care   Multispecialty group (3 or more total)   Hospital in-house   Urgent Care     Is spouse's employment  a factor in the decision No    Yes    Not Applicable If so, Spouse's profession     Desired recreational activity(s) Hiking/Camping Ocean   Lake(s)   River(s)   Fitness Center   Golf   Downhill skiing   Hunting   Tennis Other    Visa Status   US Citizen   Permanent Resident/Green Card   H1B   J1            State(s) where you are licensed and license number(s) DEA license number                Copy and Paste Resume THIS INFORMATION WILL BE KEPT CONFIDENTIAL