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* 1. Based on your review of this material, how likely are you to join CTC? (check one)

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* 2. What is your nationality?

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* 3. What is your nation of origin?

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* 4. Would you be willing to provide locum tenens/telemedicine/or relocate under our plan?

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* 5. How many weeks/year (total) are you willing to commit?

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* 6. How many weeks/year (one trip) are you willing to commit? (Note: this may or may not constitute your total for the year i.e. if you offer more than one roundtrip.)

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* 7. What is your specialty/subspecialty/unique expertise?

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* 8. Where do you currently practice? (institution/country/city/state)

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* 9. Type of practice

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* 10. How many years post-specialization/residency/fellowship are you?

Do you know of any colleagues in your/other specialty that might be interested in this opportunity?

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* 11. Name of colleague

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* 12. Specialty of colleague

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* 13. Nationality of colleague

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* 14. Colleague's email

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