Please complete all fields below and then click on the button entitled "Submit Application".
Create CV
Medical Registrations (Licenses) - Please list all medical registrations (licenses) that you have obtained or are obtaining.
Professional References - A total of five references are required. Two of these references must be in your field of specialization and three of the references must have worked with you within the past few months.
Past 5 Years Experience - The following is required in order for us to obtain medical registration for you.
Questions - Please answer each question below by marking the appropriate answer below each question. Include explanations for any affirmatively answered questions.
3. Are you now or have you ever been under the supervision of a doctor for any emotional, psychological or other conditions or illnesses that might have an impact on your performance as a doctor?
4. Are you now or have you ever been the subject of any investigations, sanctions, revocations or suspensions of your medical registrations (licenses) or prescribing authority?
5. Have you ever been denied membership in or privileges at or otherwise been investigated, sanctioned or reprimanded by any medical institution, society or association?
6. Do you or any family member who will accompany you have any illnesses or disabilities that might preclude you from receiving a foreign visa on medical grounds?
7. Have you ever, voluntarily or involuntarily, surrendered or withdrawn an application for hospital privileges, medical registration (licensure) or membership to any medical college, society or association?
8. Are you now or have you ever been addicted to any drugs or alcohol?
I have completed the application and answered all of AAV Medical Staffing’s questions to the best of my ability. I swear that the information that I have provided is true and correct. I understand that any misrepresentation made by me may result in the immediate termination of any contractual relationship I form with AAV Medical as well as the retroactive termination of the medical defense funds (malpractice insurance).
I authorize AAV Medical to speak to my references, research my background, and share any information obtained with AAV Medical clients and any medical licensing boards. I agree to hold AAV Medical harmless from any liability whatsoever related to these processes. I further agree to hold the Federation of State Medical Boards (FSMB) harmless from any liability whatsoever for the provision of information to AAV Medical and/or for AAV Medical’s subsequent use of such information.
I recognize that AAV Medical’s business depends on preserving its network of clients and doctors. To this end, AAV Medical has expended considerable amounts of time, money, and energy. Recognizing AAV Medical’s investment, I agree not to introduce other doctors to the locations AAV Medical provides to me. I also agree not go around AAV Medical by accepting any type of employment position at a location where AAV Medical presents my CV for consideration for a position, or provides me with information (verbally, in writing or by any other means). Should I go around AAV Medical, in contradiction to this agreement, and establish any type of employment relationship, for myself or for any other doctor, I agree that AAV Medical is entitled to a 20% placement fee (typically paid by the hospital or practice).