FAMILY PRACTICE RESIDENCY PROGRAM

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Medical School

Year in Medical School:

Type of school:

Osteopathic
Allopathic

Applying for:  Sub-I MS-IV Inpatient Medicine Clinical Elective MS-III Outpatient MS-I Observership MS-II Observership

           If Clinical Elective / Preceptorship, please describe your rotation objectives and preferences:

Dates when you would like to do your rotation:

            First Choice:        

            Second Choice:   

            Third Choice:       

What experience and/or rotations have you completed in family medicine or rural medicine thus far?

Please write a brief statement about your interest in family medicine:

Will you be bringing family along with you?

Yes No

Do you have any family or ties in southeastern Idaho?

Yes No

         If you have any family or ties in southeastern Idaho, please explain:

Other Languages Spoken:

Are you interested in applying for residency here?

Yes No

        If yes, would you like an interview scheduled during your rotation (4th yr students only)?

Yes No