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Student Resident Form for Community Rotation

Information for this form is provided voluntarily. AHEC is required to report information about program participants. Data will be kept private to the extent allowed by law and will be referenced periodically to evaluate the effectiveness of AHEC services and programs. We appreciate your cooperation in the completion of this form

Registration for community rotations.
  • Middle Initial
  • Credentials such as MD, PhD etc.

  • Primary telephone number
  • Fax telephone number
  • List your mobile phone number
  • Another telephone number you would like to list for contacting you
  • Discipline (Select all that apply)

  • Specialty (Select all that apply)

    Identify your specialty (you may select all that apply)

    Education level already achieved. Select all that apply
  • City and State of hometown at time of high school graduation

  • List other language 1

  • List other language 2

  • Enter the (4 digit) year when you expect to graduate.

    See Regional Map:
  • Enter an alternate Email address
  • This field is for validation purposes and should be left unchanged.