Applicant Information

Full Name *

Street Address *

Apartment/Unit #

City *

State *

ZIP Code *

Phone *

Email *

Dates of URiM Program *

Which medical specialty you are interested in? Please rank your top four (4) choices:

Family Medicine

General Surgery

Emergency Medicine

Orthopedic Surgery

Internal Medicine

Obstetrics & Gynecology

Which County would you prefer to rotate? Please rank all three (3) choices in order of preference. (subject to availability)

Chambersburg

Lebanon

York

What are you looking to gain from this experience? *

What does diversity in medicine mean to you? How do you think your identity and lived experience will play a role in your future career? *

Education

High School

From

Address

College

From

Address

Medical School

From

Address

References: Please include 1-2 letters of professional references

Reference 1

Reference 2

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to approval of externship, I understand that false or misleading information in my application may result in externship cancelation.

Signature *

Date *