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* 1. Please enter your contact information.

We communicate primarily through email so please ensure the email below is one you check regularly.

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* 2. Please list your permanent address below. This is be the address you will file your taxes at. This is where we will send your 1099 so please be sure it is accurate

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* 3. Gender

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* 4. Ethnicity

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* 5. Date of Birth

Date

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* 6. Which medical school are you enrolled in? Please note: You must be currently enrolled in a Texas medical school in order to apply for the program.

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* 7. Year of Medical School?

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* 8. In what field do you intend to practice medicine?

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* 9. Do you speak language(s) other than English? Please choose all that apply

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