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Candidate Registry
Candidate Questionnaire
This Questionnaire is 100% Confidential and Not Published.
Are You Interested In:
Check All That Apply
Associate Oppourtunity
Starting a New Practice
Buying a Practice For Sale
Name
First
Last
Postfix
Check All That Apply
DDS
DMD
MD
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Email
Tell Us About Yourself
Marital Status
Single
Engaged
Married
Divorced
Widowed
Other
Spouse's Name
First
Spouse's Occupation
Children/Ages
Your Hometown
Spouse's Hometown
US Citizen
Yes
No
Visa Status
Hobbies or Special Interests
Other information you would like to share?
Current Status
Select All That Apply
Actively Practicing
Board Certified
Board Eligible
In Fellowship
Military
Resident
Preferred Locations
Preferred Locations in Florida to Practice
Professional Information
College/Undergrad
Date Completed
MM slash DD slash YYYY
Dental School
Date Completed
MM slash DD slash YYYY
Medical School (If Applicable)
Date Completed
MM slash DD slash YYYY
Residency
Date Completed or Anticipated Date of Completion
MM slash DD slash YYYY
Fellowship (If Applicable)
Date Completed or Anticipated Date of Completion
MM slash DD slash YYYY
Regional Boards
What Dental Licensing Board Have You Taken or Plan To Take?
Date of Completion or Anticipated Date of Completion of Board Above:
MM slash DD slash YYYY
Malpractice History
Have You Ever...
Been Convicted of a Felony
Been Named in a Malpractice Suite
Had a License Suspended, Revoked, or Limited
Had Hospital Privileges Suspended or Revoked
Been Treated for Drug or Alcohol Abuse
If Yes to Above, Please Explain and Attach Any Documents if Needed
General Questions
If You Are Leaving A Practice, Please Explain Departure Reasons:
Preferred Scope of Practice:
Is Doing Hospital Based Surgery Regularly Important?
Yes
No
If Yes, Please Describe:
Describe Your Ideal Work Environment, Work Schedule, and Office Necessities:
Compensation as an Associate- Define Your Ideal Compensation Package:
Desired Start Date:
MM slash DD slash YYYY
Files
Attach CV
Max. file size: 2 GB.
Attach Cover Letter
Max. file size: 2 GB.
Attach Photo
Max. file size: 2 GB.
Website
This field is for validation purposes and should be left unchanged.
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