Name of applicant Speciality Board certified Yes No Eligible What type of work do you do now? Employed Locums Type of work interested in Location of interest Pay rate expectation Dates available MM slash DD slash YYYY Why do you want to do locum tenens? Do you have a claims history? Skill setDo you do procedures? If so what type? Do you have ER experience? How much? Do you work in open ICU setting? Do you see pediatric patients in clinic setting? Do you round on pediatric patients? Comments of person conducting the interview (comment any red flags or areas of concern during the interview):Name of person conducting the interview: Signature of medical directorPhoneThis field is for validation purposes and should be left unchanged.