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* 1. First Name

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* 2. Last Name

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* 4. Please enter your UNE e-mail address

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* 5. What is your expected year of graduation?

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* 6. On a scale of 1 (low) – 10 (high), how would you rate your interest in working as a clinician in a rural community?

1 (Low) 10 (High)
i We adjusted the number you entered based on the slider’s scale.

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* 7. On a scale of 1 (low) – 10 (high), how would you rate your interest in working as a clinician with an urban underserved community?

1 (Low) 10 (High)
i We adjusted the number you entered based on the slider’s scale.

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* 8. Describe your career goals/interests in working with rural or underserved populations. (250 words or less)

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* 9. Ultimately, where do you think you would like to practice after graduating? (250 words or less)

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* 10. Please describe the types of experiences you've had living and/or working in a rural area or with underserved populations. (250 words or less)

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* 11. What do you hope to gain from the CUP AHEC Scholars program that will enhance your ability to work with rural or underserved populations? (250 words or less)

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