Doctor Questionnaire

First Name

Last Name

Email

Phone

Qualifications

Position required:
VR GPNon- VR GP

Current professional status:
VR GPNon- VR GPGP Registrar

Are you under moratorium?
YesNo

If yes, how many years are remaining? (Leave blank if not applicable)

Year in Training:

RMO Year:

What type of employment would you like to consider? (You may select more than one):
Locum placementsMid-term employment:1- 2 yearsLong term employment: 2 or more yearsPermanent employmentAny of the aboveOther:

How soon would you be looking to start if a suitable match was found for you?ImmediatelyWithin 3 monthWithin 6 monthsOther:

Do you have a preference for city or country?CityCountryEither would be fine

Please specify which MM locations (You may select multiple MM classifications):
MM 1MM 2MM3-4MM5-6

Preferred area of work:
GP PracticeED Dept at a HospitalHospital Medical officerOther specialty:

Other comment: