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Grace Associates
     PHYSICIANS      EXCELLENCE IN PHYSICIAN PLACEMENT

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Privacy Statment

Contact Us

Physician Registration

If you are seeking the perfect physician candidate, Grace Associates can help! We will have a detailed conversation with you to find out exactly what your needs are. You need to let us know of any special requirements involved so we will present you qualified candidates that match your opportunities.

Step 1: Physician Information:
The first step in the process is to answer a few questions about yourself. Unfortunately, if you do not provide us with information in all required fields, we will be unable to contact you, even if your background and experience appear to be a good match for one of our job opportunities.

You must complete all entries marked with an “*” asterisk.

First Name*:
Last Name*:
Address*:
City*:
State*:
Zipcode*:
Home Phone*:
Office Phone:
Mobile Phone:
Pager:
Email Address*:
Web Site:

Spouse:
Spouse Occupation:
Children Ages:
Any Special Needs?:
Personal Interests:
Regional Geographic Preference*:
Detailed Geographic Preference:
Citizenship Status*:
 
Step 2: Professional Profile
To help us understand your background please answer a few questions about your qualifications and your education history. You must answer all questions marked with an “*” asterisk.
Please list Medical School(s) and dates attended.
Medical School*:
From*: To*:
Medical School:
From: To:
Medical School:
From: To:

Please list Residency and dates.
Residency*:
From*: To*:

Please list Fellowship and dates.
Fellowship:
From: To:

Please specify your current Board Status.
Board Status*:

Please summarize your malpractice history and/or disciplinary actions.*


* Required fields

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