Please fill out the following information to be considered for an associate position in one of our HealthSource clinics.


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What area in the country would you like to practice?	Doesn't Matter 1st Choice   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts 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 Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Are you licensed in this state?          Select Yes No 2nd Choice  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts 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 Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Are you licensed in this state?          Select Yes No
How soon are you looking to go into practice ?	Select 30 days 60 days 90 days 180 days 1 year
What are your five year Goals?
What are the predominant Chiropractic techniques you practice?
Do you have any specific philosophies on patient care?	Select Yes No
If yes, please explain:
What are your greatest strengths and weaknesses?
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