Please complete all of the information below:

After you have submitted this form, please forward an electronic copy of your CV along with Proof of Board Certification to recruiter@medtext.net. If you do not have an electronic copy, you can fax to (310) 379-5183 (please include a cover sheet with your name and specialty so we can match your documents with your online submission). Your submission cannot be considered complete until the CV and Proof of Board Certification is received.

Thank you and we look forward to working with you!

Full Name:

Address:

City, State, Zip

Phone:

Email:

State License Number:

University:

Current Position :

Please submit two (2) practice questions as a sample writing including:

• question
• five choices (A, B, C, D, E)
• correct answer
• explanation (two complete paragraphs)
• and reference (must include page numbers and be dated within 3 years)

Question/Answer 1:

Question/Answer 2:

Don't forget!
After you have submitted this form, please forward an electronic copy of your CV along with Proof of Board Certification to recruiter@medtext.net. If you do not have an electronic copy, you can fax to (310) 379-5183 (please include a cover sheet with your name and specialty so we can match your documents with your online submission). Your submission cannot be considered complete until the CV and Proof of Board Certification are received.