PERSONAL:

Name
Email Address
Confirm Email
Address 1
Address 2
City, State/Prov, etc.
Phone-Home
Phone-Work
Phone-Fax
Cell-other
Country of Birth
Country of residence

Marital status:  Married    Single    Divorced

LOCATION:
Which country(ies) are you interested in?
Length of time you plan on staying:   Permanently     2-5 years 6 mo-2 years     under 6 months    
Have you been to this/these country(ies) before? Yes     No
Where?      Purpose? 
Have you ever lived in a foreign country? Yes     No

How do you plan on supporting yourself while practicing abroad?

LANGUAGE:
Which languages do you speak fluently?  
How advanced is your non-English language? Speak only Speak and Understand Speak and Read Speak, Read and Write Select best choice from this drop down Menu
Which other languages do you show "some" proficiency?  

PROFESSIONAL:
Chiropractic college you graduated from:  
Yr of graduation:   
Licensed in:    i.e.: Prov./ State
Current practice status: full time part time retired  
- other  
Current average monthly patient visit volume:   PV
Would you qualify to teach chiropractic subjects abroad?   Yes* No
(* You would have to qualify to teach at University levels.)
List teaching qualifications:  

FINANCIAL:
What is the minimum monthly salary that will be acceptable?  
Would you be willing to sign a contract for a minimum of 2 years?   Yes No
Can you invest in a clinic (private or shared)?   Yes No

MOTIVATION: (briefly)
What are your personal reasons for wanting to practice abroad?

Do you have any personal contacts in this/these country(ies)?

Are there legal reason why you want to practice elsewhere?