Z Locum Provider Registration

Please complete the following form to complete your profile and register for ZLocum.com.

First Name    (Required) Middle Initial 
Last Name (Required)
Medical Title Other Title (Required)
Primary Specialty (Required)
Certification  (Required)
State Licenses 
(Required)
PC: For multiple states, hold down the Control button while selecting states
in which you are licensed
Mac: Hold down shift and select states
Job Duration   (Required)
Your Address  (Required)
City  State Zip  (Required)
Contact Phone  Number  i.e. - 123-456-7890 (Required) 
Fax Number  i.e. - 123-456-7890
Pager Number  i.e. - 123-456-7890
Geographic Preference 
(Required)
PC: For multiple preferences, hold down the Control button while selecting states
Mac: Hold down shift and select states
E-mail Address  (Required)
E-mail Address Confirmation  (Required - Please retype to confirm)
How did you hear 
about us? 		 If Other: (Required)
   
Profile Options Allow healthcare facilities to view your ZLocum.com profile
       (Facilities will NEVER see your name, address or phone number but will        see your specialty information, education, internships and residencies.)
Do NOT allow healthcare facilities to view your ZLocum.com profile
        (Facilities cannot view your profile to contact you about job opportunities)
Select your user name  (Required - must be between 3-9 characters; no spaces)
Choose a password  (Required - must be between 3-9 characters; no spaces)
Confirm password  (Required - retype to confirm)