KMSL Questionnaire

First Name:

Last Name:

Home Telephone Number:

Home Email address:

Home Address:

Home City:

Home State:

Home Zip:

Primary care Residency Specialty:

Date Primary Care Residency Was or Will be Completed:

Practice Name:

Practice Address:

Practice City:

Practice State:

Practice Zip:

Practice Telephone Number:

Practice Speciality:

Practice County:

Practice E-Mail Address:

Kansas Medical License Number:

Date Practice Began or Will Begin:

If you are changing locations, what date did you complete practicing at your prior location:

Will you be working full-time, with full time being defined as 45 hours/week not including on call hours?
Yes No

If not, how many hours will you working (excluding on call hours)?