Personal Contact Information

* Last Name:
* First Name:
Address 1:
Address 2:
* City:
* State:	ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
* Zip Code:
Home Phone:
Cell Phone:
Home Email Address:
Preferred Method of Contact:	Email Home Phone Work Phone Cell Phone

Work Contact Information

* Current Title:
Employer Name:
Employer Address:
Work Phone:
Work Email Address:

Career History

1. Provide an overview of your career progression. Include titles, a brief description of the work environment and areas of accountability. Please account for position changes and any gaps in employment. Please DO NOT indicate "See Resume".

Professional Accomplishments

1. Please provide a description of your most significant professional accomplishments.

2. Describe how you have impacted day to day core cardiac and/or vascular services operations to ensure cost sensitive quality patient care and how your work has impacted financial performance.

3. Describe your leadership role(s) and experience(s) in developing, implementing, turning around, streamlining, championing, and/or advancing new services, programs, and/or product lines within or to advance cardiac and/or vascular services delivery.

4. Describe your methodology/philosophy/style for interacting with physicians and how you incorporate them into your administrative processes.

5. What is it that uniquely sets you apart from your peers?

Personal and Family

1. Please provide a thumbnail sketch of your family and include information that will help guide us in providing information or service to you.

2. Assuming that the location, position and compensation are acceptable, what, if any other impediments exist that could complicate your making a move?

Current Compensation

1. Base Salary:   per

2. Date of next salary adjusment:

3. Percent Increase expected:  %

4. Bonus Eligible:  YES NO

5. If yes, what percentage and upon what criteria is the bonus predicated?:

6. Amount/percentage of your last bonus and when received:

Amount:

Date:

7. Amount/percentage and date of next anticipated bonus:

Amount:

Date:

8. List benefits: Include insurance, retirement programs, membership dues, holidays, vacation, other time off, all employer provided allowances and any other compensation for which you are eligible:

Position applying for:

All Open Positions Conemaugh Memorial Medical Center - Electrophysiologist DuBois Regional Medical Center - Cardiovascular CNS Good Samaritan Hospital - Medical Director of Cardiothoracic Surgery Gwinnett Medical Center - Cardiac Surgery CNS Maui Memorial Medical Center - CV Program Director Mountain States Health Alliance - Invasive Cardiologist Northside Hospital Atlanta - Cardiology CNS Northside Hospital Cherokee campus - Non-Invasive Cardiologist Portneuf Medical Center - Neurologist Satilla Regional Medical Center - Non-Invasive Cardiologist South Jersey Health Center - Vascular Surgeon St. Joseph Regional Medical Center - CT Surgeon St. Lukes Episcopal Hospital - Clinical Director Cath Lab Wheaton Franciscan Healthcare All Saints Medical Center - CVOR Manager Yavapai Regional Medical Center - Interventional Cardiologist

Do you have an interest in speaking with a Corazon representative regarding Interim Management opportunities:

YES NO

Security Code:

Attach current Resume/CV in PDF or WORD format (maximum size 500kb):