Section A: GENERAL INFORMATION
Date Format: MM slash DD slash YYYY
Section B: COMMUNITY BACKGROUND
In the following section, enter the communities (A through D, if appropriate) in which you have lived the longest.
Indicate the number of years you resided in each community (rounded to the nearest whole year). Include the community size by using one of the community designations (use the number) below.
- Small town (population less than 2,500)
- Small city (2,500 to 20,000)
- Medium-size city (20,000 to 50,000 including suburbs)
- Large city (50,000 to 250,000 including suburbs)
- Major metropolis (over 250,000 including suburbs)
- Sub-Section A
- Sub-Section B
- Sub-Section C
- Sub-Section D
Section C: PRIMARY CARE COMMITMENT
Enclose a personal statement that explains why you are choosing to enter a primary care specialty. Include any previous
community service experience that has had an impact on your decision to become a primary care physician. Also, include
your professional goals and the special strengths you believe you may bring to a primary care specialty profession.
- The Selection Committee requires that the applicant provide at least two letters of recommendation. One
recommendation may be from a physician who knows of your interests and career goals. The second recommendation may
be from someone who knows you well enough that also knows of your interest and career goals. Both recommendations
should also address your relevant employment, commitment to primary care, community service, character skills, and
involvement in serving others.
If YES addresses the funding source within your statement.
Section D: CERTIFICATION STATEMENT
I certify that the information given in this application is accurate and complete to the best of my knowledge and belief.
Fax or send the application and required information to the address provided on the application. We prefer receiving the information scanned to firstname.lastname@example.org.