PRECEPTORSHIP APPLICATION

Name: Social Security Number: Date of Birth: Medical School: Home Address: School Address: Home Telephone: Cell Phone: E-mail Address: Expected Graduation Date: Present Year of Training: Do you have an interest in a primary care career? Yes No If you have answered yes to the above question, what speciality? Have you received your Hepatitis B Vaccination? Yes No (NOTE: A vaccination and a copy of your recent physical is advised before beginning the program) Available Period (inclusive dates, list any flexibility/restrictions) Please list any training sites/locations you may prefer Please describe, in 300 words or less, why you are interested in this program Do you have an interest in participating in an International rotation? Yes No If you answered Yes to participating in an International rotation, please describe, in 300 words or less, why you should be selected for an International rotation?