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Personal Profile

Note: This is not an employment application and all questions are optional. This information will be used to help match you to a possible employment opportunity.

Contact Information
Name

Address

City
State
Zip Code
Email Address
Work Phone
Home Phone
Mobile Phone
Fax
 
Professional Information
Current Status
    Student     Fellow     Intern/Resident     In Practice
Degree(s)
State License(s)
Restrictions (if any)
Specialty
Board Certified
Sub-Specialty
Board Certified
Interested in Loan Repayment Programs? Yes   No
If applicable, what is your NHSC Status?
    Loan Repayment Recipient       Scholarship Recipient
Do you have any special Visa sponsorship needs?
(example: J-1, H1-B)
 
Practice Information
Interested In
Location / Population Preference
   
List in order of priority, important factors you and/or your spouse
consider when selecting a place to practice and live in Texas.



 
Additional Information
If bilingual, please specify lanaguage(s) and level of fluency
Why have you chosen to practice in Texas?
What is your reason for moving/changing your present work situation?
How did you hear about TACHC?
Is there any additional information you'd like TACHC to know?
(hobbies, spouse's occupation, family members' interests, ...)
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