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Program Director In-take
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Name
*
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Service
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Commission Source
ROTC
ACADEMY
USUHS
HPSP
Other:
Email 1
Your answer
Email 2
Your answer
Phone Number
Your answer
Name of Medical School
Your answer
Degree from Medical School
MD
DO
Medical School Graduation Year
Your answer
Name of College or Colleges
Your answer
College Graduation Year
Your answer
Have you ever failed a USMLE/COMLEX exam?
Yes
No
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USMLE STEP 1 Score
Your answer
COMLEX 1 Score
Your answer
USMLE STEP 2 Score
Your answer
COMLEX 2 Score
Your answer
Have you ever failed any courses in medical school?
Yes
No
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If yes, which courses?
Your answer
Did it take you longer than 4 years to complete college?
Yes
No
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If yes, why?
Your answer
Will it take you longer than 4 years to complete Medical School?
Yes
No
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If yes, why?
Have you ever had remediation during medical school?
Yes
No
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Are you currently or previous been on Active Duty?
Yes
No
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Are you participating in a joint match with a married spouse?
Yes
No
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If yes, is your spouse active duty?
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Do you have a spouse or dependent that is active duty?
Yes
No
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Do you have any geographic interests you would like the Program Director to know about?
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Any other considerations or interests you would like the Program Director to know about?
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