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Project Premed Mentoring Program

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* 1. Name

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* 2. Gender

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* 3. Local Address

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* 4. Permanent Home Address

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* 5. Primary Phone

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* 6. Cell Phone Number

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* 7. Personal Email Address

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* 8. Personal School Email Address

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* 9. Birthdate

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* 10. Contact Person in Case of an Emergency

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* 11. Contact Person's Number

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* 12. Highest Level of Education Completed

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* 13. Anticipated Date of Graduation

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* 14. Name of College or University

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* 15. School Address

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* 16. Race

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* 17. Ethnicity

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* 18. High School Name

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* 19. High School City

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* 20. High School State

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* 21. I intend/plan/would like to enter a health career

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* 22. Please select your current Education Status

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* 23. What health care field/fields are you interested in?

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* 24. If you have taken the MCAT, please list your score

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* 25. Please list your Extra-Curricular Activities.

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* 26. Please upload your Unofficial Transcript

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 27. Please upload your Resume

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 28. A Brief Summary (no more than 100 words) your interest in Project PREMED

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 29. Proof of US Citizenship or Permanent Residency (Copy of Passport or Birth Certificate and Driver’s License)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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Please send your Letter of support (from university program advisor, professor, or administrator) to Mistie Crowder at stewar21@marshall.edu

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* 30. T-Shirt Size

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* 31. All applications and documentation must be received by May 16, 2022.

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