Mobile Infirmary Internal Medicine Residency Program Applicant Information Form
We are excited that you have chosen to interview with our program! Please take a moment to complete our brief applicant information form, if there are any questions you may contact LaTasha Williams, C-TAGME Program Manager at latasha.williams@infirmaryhealth.org
Name
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First Name
Last Name
Interview Date
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Month
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Day
Year
Date
Please provide a physical address (Be sure to include Postal codes; No PO Boxes please)
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Please provide your best contact phone number, we will use this number to call you to continue your interview by phone, in the event that you experience technical issues lasting more than 15 minutes on your interview day.
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24 hours prior to your interview with us, you must upload a signed copy of the attestation for applicants interviewing with Infirmary Health Graduate Medical Education Program Form
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I have uploaded a signed copy of the Infirmary Health Graduate Medical Attestation Form
Attestation for Applicants Interviewing
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I attest that I have received the Infirmary Health Graduate Medical Education Attestation Form and Sample Resident Agreement. I further understand that I must submit a signed copy of the Infirmary Health Graduate Medical Education Attestation Form to the Mobile Internal Medicine Residency Program Office prior to my scheduled interview day.If the attestation form is not received at least 24 hours prior to my scheduled interview, I understand that my interview will be canceled.
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