Prospective EMPLOYEE DVM Questionnaire Order Number Complete the form below, then click send. We will contact you shortly. First name * Last name * Street Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Email Address * Telephone Cell Number * Telephone Other School & Year of DVM degree In what state(s) are you licensed? What are your areas of special interest in the practice of veterinary medicine? Are you a member of your: State VMA District VMA AVMA What, if any, are your geographic constraints? What is your desired annual compensation? $ current annual compensation? $ What was your personal production last calendar year? $ this year-to-date? $ Are payments current on all of your personal obligations/debts? state and federal income taxes? What type of Practice do you prefer? (choose one) Emergency Small Animal only Equine only Mixed Small Animal & Equine Other What size Practice do you prefer? (choose one) Small, 2 Vet Medium, 3-4 Vet Large, multi-Vet Other Where do you prefer to practice? (choose one) Urban Rural No Preference In 35 words or less, what are your personal philosophy and goals regarding your practice of veterinary medicine? Please provide the name, address and contact information of a licensed veterinarian that may be contacted as a personal and professional reference Reference Name Reference Address Reference Telephone Reference Email How proficient are you in (choose one) Small Animal Non-Surgical Procedures? very somewhat not Small Animal Surgical Procedures? very somewhat not Small Animal Orthopedics? very somewhat not Large Animal Procedures? very somewhat not How familiar are you with (choose one) financial management? very somewhat not personnel management? very somewhat not inventory management? very somewhat not Is there anything else that you would like for an EMPLOYER DVM to know about you? Comments / Questions * By your electronic signature below, you agree as follows: All information provided to me by DVM RECRUITERS® about the identity, location, operations, finances and other details of prospective Employer-DVMs shall be held strictly confidential, except as may be shared with my agents, representatives, and legal, financial or other advisors hired by me for assistance in evaluating said prospective Employer-DVMs. I agree not to disclose any such information to any other parties. I assure compliance by my spouse (if any), agents, representatives, and legal, financial or other advisors with the requirements of this agreement. I will not circumvent this agreement by entering directly into any oral or written offer, agreement or employment with any prospective Employer-DVM introduced to me or whose identity has been made known to me by DVM RECRUITERS®, without the specific knowledge and consent of DVM RECRUITERS®. Enter your initials here (as your electronic signature) *
