First Name:
Last Name:
Email address:
Home Phone:
Cell Phone:
CONTACT INFORMATION AT TIME OF ORDER:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip Code:
CURRENT CONTACT INFORMATION (if different):
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut Territory
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Zip Code:
Current Employer:
How long have you been employed with this employer?
yrs,
mos
ORDER INFORMATION:
Purchase date:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
2
3
0
1
2
3
4
5
6
7
8
9
,
2010
2009
2008
2007
2006
2005
2004
2003
Total amount:
Representative Name:
Date package was received:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
2
3
0
1
2
3
4
5
6
7
8
9
,
2010
2009
2008
2007
2006
2005
2004
2003
Date letters were mailed:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
2
3
0
1
2
3
4
5
6
7
8
9
,
2010
2009
2008
2007
2006
2005
2004
2003
(if you paid for The Doctor Job to do the mailing, please select the date that you received the folder with the tracking information)
SEARCH RESULTS INFORMATION:
Number of letters mailed:
Number of letters unmailed (if any):
If unmailed letters, please give your specific reasons for not mailing each letter:
Number of undeliverable letters:
Please list, in explicit detail, all responses received , including the name of the person who contacted you, the result of the conversation, and the date of the interview, if any:
Did you receive any offers for employment?
Yes
No
If yes, please give your reasons for not accepting each offer:
In which state(s) were you searching?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you licensed in each state?
Yes
No
Some, but not all
When did you graduate from your residency or fellowship (whichever was later)?
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
2
3
0
1
2
3
4
5
6
7
8
9
,
2010
2009
2008
2007
2006
2005
2004
2003
Before 2003
Do you have anything in your background that prevents you from getting an unencumbered medical license in any state in the US?
Yes
No
Has your medical license ever been suspended for any period of time or for any reason?
Yes
No
Please use this space to provide any additional information that can prove helpful in reviewing your case and determining your eligibility under the guarantee:
I attest, under penalties of perjury, that the information and statements that I have provided in this form are true, complete and accurate, and that I understand that providing false, incomplete or inaccurate information will invalidate any rights to which I may otherwise be entitled under the guarantee. Furthermore, I attest that I have read, understand, and agree to the terms of the guarantee as described online here , and the Terms and Conditions as described online here .