McLaren Greater Lansing Application for Osteopathic/PA Elective Clerkship

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I wish to apply for the following rotations: 
3 Rotations Maximum
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Contact Information

Name: (last, first, middle initial) *

Phone Number: (000)000-0000 *

Email:  *

Academic Year:  * 
Last 4 Digits of SSN#:  *

Date of Birth: *

Present Address

Address: *

City, State, Zip: *

Osteopathic/PA School:

College (1): 
City, State, Zip: 
Phone (000)000-0000:  

Previous Clerkship Experience:

Check box or list if completed or in progress:

Do you have Personal Health Insurance? *

Do you have any Physician, Mental, or Substance Abuse Problems which, to your knowledge, could interfere with your ability to perform the essential funcations of the job and-or complete the ridorous requirements of Residency Training Program?
If Yes, Please Describe the Problem, Related Therapy, Etc. (Send Documentation as Necessary):
Do You Have an Armed Services Commitment?
If yes, Please Describe:
I agree that the above is true to the best of my knowledge, initial here