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IF YOUR OPPORTUNITY IS **URGENT** DO NOT FILL OUT THIS FORM, BUT, INSTEAD CALL US IMMEDIATELY AT 800-600-0963

There's no charge and no obligation if you wish to tell us the dates for which you need coverage of your practice.... or your criteria for hiring an Associate/Partner. If we have a potential match for your needs — and we will, sooner or later — we'll contact you to tell you about the credentials of the prospect. You decide if you'd like to speak to them. You're in charge. We simply expedite the process.

About Your Practice
*Email Address
*First name
*Last name
*Professional title
*Practice Address
(line 2, if necessary)
*Practice City
*Practice State
*Practice Zip
Business Phone
Home Phone
Cell Phone
Fax Phone
Describe The Opportunity
*Reason for opportunity
*Skills Required
*Type of Dentistry
First date coverage required	(mm/dd/yyyy)
Approximate TOTAL number of days coverage is required	(#'s only - no $ or commas)
*Type of position
*Is this opportunity confidential?
Office manager name
*Describe this opportunity so that is almost sells itself!