Name of Advisor or School Contact: ___________________________________________

Advisor or School Contact's Address: __________________________________________

Street/PO Box: ____________________________________________________________

Apartment: ___________________

 City/Town: ______________________________  State:__________  Zip: ____________

Contact Phone: __________________   Email Address: ____________________________

Current Year in Professional School or Residency Program:

                  ____   Year 01
                  ____   Year 02
                  ____   Year 03
                  ____   Year 04

Anticipated Graducation Date: _________________________

Birth Place: _____________________________________________________________

High School Attended: ____________________________________________________

Enrollment [if known]   ____ <100   ___ 100-600    ___601-1200    ___1201-1800     ____>1800

 City/Town: _______________________________  State:__________  Zip:__________

State of Legal Residence: __________________

Rank the type of community in which you plan to practice (1=Highest & 5=Lowest):

Rural ____       Small Town ____       Suburban ____     Inner-city ____     City ____

Rank your specialty preference in your rotation/internship (1-first choice):

Family Practice ____      Internal Medicine ____       Pediatrics Obstetrics& Gynecology

Marriage & Family Counseling ____      Other Mental Health ____      Dental ____

____ Other [Please Specify] _________________________________________________