Request Information About: Locum Tenens/Volunteers

This is the form to request information for Locum Tenens and Volunteer Positions in the Indian Health Service. Please enter the specifics of your request in the notes, comments, or questions field at the bottom of the form. You will have the opportunity to upload your CV and cover letter of intent when you complete this online form. We cannot market your availability unless you provide this preliminary information.

Note: You will need a background check and fingerprint card before your start date.

* Indicates Required Field

Name Prefix:* Dr. Mr. Mrs. Ms. First:* Middle: Last:* Suffix: Title: DO MD

Address Street:*   City:* State:* No state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands Guam American Samoa Micronesia Marshall Islands N. Mariana Islands Palau Armed Forces AE Armed Forces AA Armed Forces AP Zip Code:* Alternate Address Street:   City: State: No state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands Guam American Samoa Micronesia Marshall Islands N. Mariana Islands Palau Armed Forces AE Armed Forces AA Armed Forces AP Zip Code:

Phone Numbers Home Phone:* () - ext. Work Phone: () - ext. Alt Phone: () - ext. Email Address Primary Email: Alt Email:

Qualifications School:* Graduation Date:* (mm/dd/yyyy) Degree Type:* (CTRL-click to select multiple) DO (non-US trained) DO (US trained) MD (non-US trained) MD (US trained) Please check all certifications that you possess:  BCLS  ACLS Please check all specialties that apply to you: Anesthesiology Ear Nose and Throat Emergency Medicine Family Medicine Internal Medicine Internal Medicine/Pediatrics Obstetrics/Gynecology Ophthalmology Orthopedics Other (specify in notes below) Pediatrics Psychiatry Radiology Surgery

Preferences Preferred Location: Unknown Flexible Geographic Location:      NW NE SW SE IHS Area: Aberdeen Area Alaska Area Albuquerque Area Bemidji Area Billings Area California Area Nashville Area Navajo Area Oklahoma Area Phoenix Area Portland Area Tucson Area State:     No state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Islands Guam American Samoa Micronesia Marshall Islands N. Mariana Islands Palau Armed Forces AE Armed Forces AA Armed Forces AP Length of time available for TDY:* 2 weeks or less 2 weeks - 1 month 1 - 3 months 3 - 6 months 6 months or more Flexible When are you available? Unknown Flexible Seasonal: Spring Summer Fall Winter Monthly:  January February March April May June July August September October November December

Additional Information How did you find out about us?* Conference Direct Mail Federal Employee/Tribal Member Friend/Co-worker/Relative Internet Journal Newspaper Other PHS Recruiter Poster Radio School Employee Television Trade Magazine      If you found out about us from an "Other" source, please specify: Notes, comments, or questions: