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Premier Membership Application

* First Name:
* Last Name:
Company:
* Address:

* City:
* State:
* Zip:
* Email Address:
Website:
* Phone:
Fax:

Have you ever had any malpractice actions within the past five years (pending, settled, arbitrated, mediated or litigated)?
Yes No

Has your license to practice, in your profession, ever been denied, suspended, revoked, restricted, voluntarily surrendered while under investigation, or have you ever been subject to a consent order, probation or any conditions or limitations by any state licensing board?
Yes No

* Reference 1
Name Address Phone Email Comments
* Reference 2

* Reference 3

* I have been in practice for	years
* Primary Specialty:
Other Specialty Area:
My primary specialty area makes up	% of my practice

How did you find PremierDoctors.com?

From Search Engine:	Yes No
Link from another Web site:	Yes No
If yes, name of that Web site:
From another physician:	Yes No
If yes, name of that Doctor:
The Premier Doctors Program Director referred me:	Yes No

* These fields are required.