Let's Get Acquainted - Corey Medical Consultants,Inc.

Corey Medical Consultants, Inc.
Practice Management Consultant's Form

We would like the opportunity to answer your questions and discuss becoming an independent
Corey Medical Consultant in more detail. Please complete and submit the form below:

Personal Info

First Name:

Middle Initial:

Last Name:

Address:

City, State:

Zip Code:

Primary Phone:

Secondary Phone:

Email:

Best Time To Call:

Preferred Method of Contact:

Professional Info

Current Occupation:

Employer:
(include City & State)

Position/Duties:

Previous Employer:
(include City & State)

Position/Duties:

Territory of Interest:

Timeframe to start new career:

ASAP

1-3 Months

3-6 Months

6-12 Months

Hours/Days you can devote
each week to your business:

Would you operate the business:

Education - Highest level Attended:

Graduated:

Degree:

Additional Degree or Certification:

Have you previously owned and operated your own business?

Describe:

Have you previously worked in the medical industry:

Describe:

Experiences/Education/Training related to the CMC business:

How did you locate our site?

Electronic Signature:
(Enter your full name)

Checking this box verifies your Signature and is the
legal equivalent of a
hand-written signature.

Thank You:

We respect your privacy. Any information submitted to us with this form will remain private and confidential, and we will not share your information with any outside organization. Submitting your inquiry does not create an obligation.

PO Box 79223Dartmouth, MA 02747

telephone 508.496.1546

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