City, State, Zip Code s6

RECRUITER411 Submission Form Instructions: Complete this submission form - please type if possible (place cursor over gray boxes, which will expand accordingly). You may then save a completed copy and return it as an email attachment to [email protected] or fax to (800) 355-2277.

CONTACT INFORMATION Submission Contact Billing Contact (Complete only if different from Submission Contact) Organization Name: Organization Name: Your Name: Name: Title: Title: Department: Department: Mailing Address: Mailing Address: City: State: Zip: City: State: Zip: Email: Email: Phone: Fax: Phone: Fax: PAYMENT OPTIONS: Check One Pay by CREDIT CARD (provide card information below) Receive invoice by EMAIL Card Number: Exp: Receive invoice by REGULAR MAIL Type: MasterCard Visa AMEX Discover TERMS & CONDITIONS Card Verification Code: Name on Card: Please proofread your submission carefully - content will be published Card Billing Address: exactly as you submit it and may not be edited once submitted. City: State: Zip: ORDER INFORMATION: Indicate the RECRUITER411 directories in which you would like to appear.

RECRUITER411 - Upcoming Issues Regional Recruiter National Recruiter (select all regions that apply) (includes your directory listing in all regions) Emergency Medicine Northeast $145 Midwest $145 To appear in CAREER INSIGHTS EM $580 Volume 1, Issue 2 Deadline: 11/07/08 South $145 West $145 Family Medicine Northeast $145 Midwest $145 To appear in CAREER INSIGHTS FM $580 Volume 4, Issue 2 Deadline: 12/12/08 South $145 West $145 Internal Medicine Northeast $145 Midwest $145 To appear in CAREER INSIGHTS IM $580 Volume 5, Issue 2 Deadline: 10/31/08 South $145 West $145 Neurology Northeast $145 Midwest $145 To appear in CAREER INSIGHTS NEURO $580 Volume 1, Issue 2 Deadline: 11/28/08 South $145 West $145 Obstetrics & Gynecology Northeast $145 Midwest $145 To appear in CAREER INSIGHTS OB/GYN $580 Volume 4, Issue 1 Deadline: 1/23/09 South $145 West $145 Orthopaedic Surgery Northeast $145 Midwest $145 To appear in CAREER INSIGHTS ORTHO $580 Volume 4, Issue 1 Deadline: 1/16/09 South $145 West $145 Pediatrics Northeast $145 Midwest $145 To appear in CAREER INSIGHTS PEDS $580 Volume 2, Issue 1 Deadline: 1/09/09 South $145 West $145 Psychiatry Northeast $145 Midwest $145 To appear in CAREER INSIGHTS PSYCH $580 Volume 1, Issue 2 Deadline: 11/21/08 South $145 West $145 Surgery Northeast $145 Midwest $145 To appear in CAREER INSIGHTS SURGERY $580 Volume 1, Issue 2 Deadline: 11/14/08 South $145 West $145 Urology Northeast $145 Midwest $145 To appear in CAREER INSIGHTS URO $580 Volume 1, Issue 2 Deadline: 12/05/08 South $145 West $145 Anesthesiology Northeast $145 Midwest $145 To appear in CAREER INSIGHTS ANESTHESIOLOGY $580 Volume 1, Issue 2 Deadline: 12/19/08 South $145 West $145 YOUR RECRUITER411 LISTING INFORMATION Recruiter Name: Title: Organization Name: Address: City, State, Zip Code: Phone Number: Fax: E-Mail: Website: