Student Training Programs
Environmental Medicine Rotation Program (EMRP)

APPLICATION

Environmental Medicine Rotation Program

APPLICANT INFORMATION
Last Name:
First:
M.I.:
Street Address:
Apartment/Unit #:
City:
State:
ZIP:
Phone:
E-mail Address:
Dates Requested:
Social Security No.:
Position Applied for:
Are you a citizen of the United States?
Yes No
If no, are you authorized to work in the U.S.?
Yes No
Have you ever been convicted of a felony?
Yes No
If yes, explain:
EDUCATION
College:
Address:
From: To:
Did you graduate?
Yes No
Degree:
Graduate/Med. Sch.:
Address:
From: To:
Did you graduate?
Yes No
Degree:
Other:
Address:
From: To:
Did you graduate?
Yes No
Degree:
TRAINING/GRADUATE PROGRAM INFORMATION
Program Name:
Program Director/Chair:
Institution:
Phone:
Address:
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Yes
Required Attachments:
Approval Letter from Program Director/Department Chair:
Current CV:
Completion of CDC Security Clearance Forms (Provided):

Program Director
Environmental Medicine Rotation Program
Morehouse School of Medicine
NCPC, 335
720 Westview Drive, SW
Atlanta, GA 30310-1495
Email: cdurham@msm.edu