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| Name* |
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| Email* |
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Possible start date*
(mm-dd-yyyy) |
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| Licenses you have* |
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| Licenses in progress* |
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| City and State you are located in* |
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| Teleradiology experience* |
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| Are you currently setup to receive and view images at home?* |
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| Any malpractice claims against you?* |
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| Are you seeking full-time or part-time position?* |
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| List number of hours with preferred timings you would like to
work for* |
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| Approximate volume of prelim studies (night volumes are 95% CT with abd/pelvis as 1 study for the sake of argument) you could read over a given period (i.e.. per hour, or day)* |
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| Phone number and best time of day for a continued discussion* |
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| Describe your ideal teleradiology position* |
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| Please include an updated copy of your resume*
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