UMPR - Upper Midwest Staff Physician Recruiters Association

Membership Request Form (* indicates required fields)

Name*
Title*
Hospital/Group/System*
Email*
Web*
Phone*
Mobile Phone*
Fax*
Address*
City*
State and Zip*
Description of Your Organization
Residency Programs in Your Organization
What percent of time is devoted to physician recruitment?
How many years of experience do you have?
Highest Educational Degree
Is a fee charged for recruited physicians? If yes, please explain structure.

*Attention:* If any required field is left blank, all information will be deleted.