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Military Medicine Ambassador (MMA)
*
1.
Contact Information
(Required.)
First Name:
Last Name:
Email Address:
Personal (Permanent) Email Address:
Preferred Phone Number:
Primary Work Location (e.g., Walter Reed National Medical Center, Purdue University)
Home Street Address
City in which you live:
State in which you live:
Zip Code
Hometown:
2.
Current Position:
Military or Civilian Physician
University Faculty/Staff Member
Pre-Health/Med Advisor
Student
Other (please specify)
3.
Educational Institution(s) Attended:
Undergraduate:
Graduate:
4.
Branch of Service, if applicable:
U.S. Air Force
U.S. Army
U.S. Navy
U.S. Public Health Service
5.
Current Rank, if applicable:
6.
If Alumni, USU Graduation Year:
7.
Area of Medical or Research Specialty:
Specialty:
Subspecialty:
8.
I would be interested in:
Representing USU by speaking, visiting, or sharing information at campus events.
Hosting student discussions or groups.
Providing support to USU Recruiters during campus visits.
Mentoring pre-medical students.
9.
Areas willing to Recruit:
Nationwide
Within my residential state
At my alma mater(s)
Other (please list in space below)
10.
If you'd like
to leave any comments for us, please do so here!
