Join Us

If you are interested in becoming an esteemed member of QTC's provider network, fax a copy of your curriculum vitae to 909-861-6281 or complete the online interest card below and a QTC representative will contact you within 48 hours of receipt.

**Refer a qualified examiner and you may qualify for a $100 reward.**

Interest Card

Physician Information

First Name:*		Last Name:*
Title:		Group:
Specialty:		Board Cert/Eligible:	Yes No
License (1):
#:*   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming   Exp Date:
License (2):
#:   State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming   Exp Date:

Contact Information

Contact Name:			Title:
(if diff. than above)
Address(1):			Address(2):
City:		State:	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	Zip:
Phone(1):*			Phone(2):
Fax:			E-mail:

Additional Information

Questions/ Comments:
How did you hear about QTC?	Conference/Event		Brochure/Mailer
	Job Serach Site		Print Ad
	Search Engine		Referral
	Other	Specify:
Would you like to receive periodic QTC-related news and updates to your e-mail account?			Yes No