1330 W. Peachtree Street, Suite 500, Atlanta, GA 30309-2904*   404-876-7535* 404-249-9503 fax

Please complete & fax to the chapter office.

Date: ______________________

Practice location: _________________________________________________________

Name of Lead Physician: ____________________________

Number of offices: _______________________

Number of doctors: _______________________

Contact person: ____________________________________________________

Address: _________________________________________________________

Phone: _________________________________ Fax: ____________________

E-Mail: ________________________________

Seeking Pediatrician/ PA/ PNP (circle one)

Full/Part time: ___________________________

Starting date (preferred) ___________________

Key requirements: _________________________________________________

Other interesting points:___________________________________________________

________________________________________________________________________

Yes                 No