LP Pre-Development Questionnaire

Financial Information

What is your approximate current balance of your student loan debt (write N/A if none)?

Do you currently have personal debt greater than $20,000 excluding student loans?

Please specify types and approximate balance(s) of personal debt greater than $20,000 (excluding student loans)?

How much capital do you have to invest in a CityVet location?

Have you ever filed for bankruptcy?

Please explain

What is your minimum income requirement for the first 12 months?

What is your minimum income requirement for the first 24 months?

Medical Practice Proficiency

Please indicate your practical experience, proficiency and confidence in the following areas. 1 is least experience/proficient/confident and 5 is most experience/proficient/confident.

This area is available for any additional explanation you want to provide for the ratings above in the Skills and Proficiency section.

How do you determine if you are able to work up a medical case or refer out?

What non-routine surgical cases have you had the most experience with? What has been the success rate?

Are there any components of general practice you are opposed to performing?

List any medicine/surgery competencies where you feel you lack experience, confidence, or need more support

References

Reference #1: Supervisor

Name

First

Last

Job/Occupation

Phone

Email

Reference #2: Peer

Name

First

Last

Job/Occupation

Phone

Email

Reference #3: Subordinate

Name

First

Last

Job/Occupation

Phone

Email