Date: -- mm/dd/yy

First Name:
Last Name:
SSN#:
Current Address:
Current City:
Current State:
Current Zip:
Date of Birth:			--mm/dd/yy
Race/Ethnicity:			African/American Asian Caucasian Native American Hispanic/Latino Native Hawaiian Other
Permanent Address: (if different from above)
Permanent City:
Permanent State:
Permanent Zip:
Phone:
E-Mail:
Academic institution in which you are currently enrolled (if applicable)
Academic Institution Name:
Academic Institution Address:
Academic Institution City:
Academic Institution State:
Academic Institution Zip:
Residency program you are in:
Residency Name:
Residency Address:
Residency City:
Residency St:
Residency Zip:
Specialty of the  residency program
Contact person (for placements) at your program:
Name:
Phone:
E-Mail:
Profession:
MD/DO	NP	PA	MSW	DDS/DMD	DH
What year are you in?
When do you anticipate completing your program? month/year
What languages, other than English, do you speak?
Fluently:
Passably:
When do you wish to participate in the Oregon SEARCH program? (If you have several options, please list them in order of preference:
1.			2.
3.
How long is your rotation?
Will you be receiving academic credit for this experience?  Yes    No
If no, will you be enrolled in your academic program during your rotation?  Yes    No
Does your academic institution/residency program cover your malpractice insurance during 'away' rotations/experiences? Yes    No
Why do you wish to participate in the Oregon SEARCH program?
What are your goals for this rotation?
Do you have a preference as to site/population/location? If more than one, please prioritize:
1.			2.
3.
What are your future professional goals?
Are you currently a National Health Service Corps Scholar? Yes    No
Please write a short paragraph about yourself, your past experiences, prior employment, etc.