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LabLeadership Executive Search^® - Medical Director Opportunities Please fill out the following form and include your C.V. using the "Upload C.V." feature at the end of this form. If your C.V. is not current, you may send it to us once it has been updated. Candidates will only be considered for client searches when we have received their C.V. You may e-mail your C.V. to us at info@hcdsinc.com, or fax it to (847) 498-3264, or mail it to: LabLeadership Executive Search^® Health Care Development Services, Inc. 2916 Idlewood Ln. Highland Park, IL 60035 When you have completed the requested information, simply click on the submit button. Your registration information will be secure through the use of Secure Socket Layer (SSL) technology.

Name:
Address:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Fax:
Email:
Current Employer:
Employer City:
Employer State:
Name of medical facilities served:
Present position(s): (check all that apply)	Chairman of Department Medical Director Section Chief Associate Medical Director Other If other, please specify:
Medical School:
Residency:
Fellowships:
Are you boarded in Anatomical Pathology?:	Yes No If yes, what year?:
Are you boarded in Clinical Pathology?:	Yes No" If yes, what year?:
Do you have a subspeciality?:	Yes No
If yes, what is your subspecialty?:
What states are you licensed?
Please indicate the type of organization in which you currently practice: (check all that apply)	Community hospital Teaching hospital Academic Medical Center Commercial Laboratory Clinic Laboratory Other If other, please specify:
Is your organization part of a multi-hospital system?:	Yes No
What type of laboratory do you work in?: (check all that apply)	Traditional stand alone laboratory Immediate response laboratory Central/core laboratory Other If other, please specify:
Professional Associations: (check all that apply)	AACC ASCP CAP CLMA ISCLT Other If other, please specify:
Laboratory Environment Desired:(check all that apply)	Integrated Healthcare System Traditional hospital laboratory Immediate response laboratory or equivalent Single lab responsibility> Multi departmental responsibility> Other If other, please specify:
What career opportunities would you be most interested in discussing?:	Medical Director Stand alone hospital Multi-Hospital System Academic Medical Center Other If other, please specify: Chemistry Hematology/Coagulation Blood Bank Microbiology Immunology Histology/Cytology Molecular Diagnostics Other Staff Pathologist If other, please specify:
Upload your C.V.: (locate file on your computer)
AFTER WE RECEIVE YOUR REGISTRATION FORM AND C.V. As soon as we receive your registration information, we will acknowledge receipt via regular mail to your home address. Once we have reviewed the information you provide, we will send you the feedback information. Thank you for registering with the LabLeadership Executive Search^® program.