Military Medicine Ambassador (MMA)

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* 1. Contact Information

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

Home Street Address 2

City in which you live:

State in which you live:

Zip Code

Hometown:

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* 2. Current Position:

Other (please specify)

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* 3. Educational Institution(s) Attended:

Undergraduate:

Graduate:

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* 4. Branch of Service, if applicable:

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* 5. Current Rank, if applicable:

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* 6. If Alumni, USU Graduation Year:

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* 7. Area of Medical or Research Speciality:

Speciality:

Subspeciality:

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* 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.

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* 9. Areas willing to Recruit:

Nationwide

Within my residential state

At my alma mater(s)

Other (please list in space below)

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* 1. Contact Information

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* 2. Current Position:

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* 3. Educational Institution(s) Attended:

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* 4. Branch of Service, if applicable:

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* 5. Current Rank, if applicable:

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* 6. If Alumni, USU Graduation Year:

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* 7. Area of Medical or Research Speciality:

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* 8. I would be interested in:

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* 9. Areas willing to Recruit:

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* 10. If you'd like to leave any comments for us, please do so here!