Recruiting Firm Referral Form to Client
We remind you that discrimination is illegal. The NAPR recognizes the need our members have to identify the best
possible candidates and we do not in any way want to deter you from that purpose. However, because the NAPR
represents the standards for our industry and consequently wishes to avoid any semblance of legal impropriety, we ask
that you refrain from using language that is determined to be discriminatory, or could be deemed discriminatory.
Submitting Firm’s Name:
Contact Name and Information of the person who has spoken to the Candidate:
MD
DO
Medical School:
Specialty:
Subspecialty:
Special Skills:
Board Certified:
Board Certified until when?
Board Eligible:
Anticipated date of taking the boards?
Resident
Fellow
Practicing Physician
US Citizen
H1-B
J-1
Green Card
Other
Geographic Preferences:
MiddleAtlantic
Delaware
Maryland
New Jersey
New York
Midwest
Illinois
Indiana
Iowa
Kansas
Pennsylvania
Washington
DC
Michigan
Minnesota
Missouri
Nebraska
North Dakota
Ohio
South Dakota
Wisconsin
New England
Connecticut
Maine
Massachusetts
New
Hampshire
Rhode Island
Vermont
South
Alabama
Arkansas
Florida
Georgia
Southwest
Arizona
New Mexico
Oklahoma
Texas
West
Alaska
California
Colorado
Hawaii
Kentucky
Louisiana
Idaho
Montana
Mississippi
North
Carolina
South
Carolina
Tennessee
Virginia
West Virginia
Nevada
Oregon
Utah
Washington
Wyoming
Desired City Size or Cities:
Rural (25,000 or less)
Small (25,000-50,000)
Medium (50,000-250,000)
Metro (250,000+)
Other _______________________
Distance to Metro area:
Less than 30 minutes
30minutes-1 hour
1 hour +
Other_________________
Names of Cities Desired:
Active License(s):
Practice Preference:
Hospital
Private Practice
Solo
Open
Current Practice Situation (If applicable):
Hospital
In training
Private Practice
Solo
Other___________
Why is the candidate looking or leaving current situation (if applicable)?
Ideal Start Date:
Date the candidate intends to make a decision?
Malpractice cases pending or settled in the past 10 years:
Yes
No
Not to my knowledge
Licensing Issues?
Yes
No
Not to my knowledge
Non-Compete?
Yes
No
Not to my knowledge
Notice to leave?
No notice needed
30 days
60 days
90 days
6 months
Other _____________
Additional Information: