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First Name
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Last Name
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Street Address
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City
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State
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Zip Code
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Gender
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Student Gender
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I am able to provide the following
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Lodging during residency interviews
Meals
Information about residency program
Transportation to interview
Assistance with finding housing once matched
Preferred Contact Time
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Email
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Travel plans
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If you will be traveling during the months of October through January (Holiday, Clinical, Rotations, etc.), please provide approximate dates of travel and the best way to reach you during these periods:
Training hospitals in your area
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Please provide full names and approximate commuting times from your home ex. University of Virginia Medical Center - 15 minutes; Martha Jefferson Hospital - 20 minutes
At what hospital did you receive your residency training?
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Please provide full name of hospital
Where was this hospital located?
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City, State
When did you complete your residency?
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Year
What is your medical specialty?
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Where are you currently employed?
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Hospital or practice name and location
What is your current position title?
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Do you have any pets
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