1.  AHEC Region:  NW    NC    SE    SW    SC    NE    EC

2.  Today's Date:  / /   (mm/dd/yyyy)

3.  Your Date of Birth:   / /   (mm/dd/yyyy)

4.  Name:    (first, middle, last)

5.  City/State of Hometown:   

6.  Your Gender:  Male    Female

7.  Your Race / Ethnicity: (Choose only one)

8.  High School Name:  

9.  High School Graduation Date:    / /   (mm/dd/yyyy)

10.  Location of High School:    (city, state, country)

11.  What is your current mailing address?

12.  Please indicate a permanent address or address of a relative or friend that will know your address after graduation.

13.  Your Current School Name: 

14.  Expected Graduation Date:  / /   (mm/dd/yyyy)

15.  Check your program of study:  (choose only one)

16.  Check if you have chosen to specialize in a primary care specialty area:

17.  Check if you are currently enrolled in or participating in a federal or state loan repayment program:

18.  What is the probability that you will eventually practice in each of the areas indicated below?  (Choose one per section)

19.  At this time, how important are the following factors in choosing a location for your practice upon graduation?  (Choose one per section)

20.  Your Email Address:    (required for internet submission)