CEMED Application

1. First Name

2. Middle Initial

3. Last Name

4. AAMC ID#

5. Current Address

6. City

7. State

8. Zip

9. Current Telephone #

10. Email Address answer must be an email address

11. Other than English, what languages are you proficient in?

While we have information you provided to the UI College of Medicine via the AMCAS and supplemental applications, we would like you to answer the following questions in relation to the Clinician Executive Medicine curriculum.

12. What experiences, skills or attitudes do you have that would allow you to learn and contribute effectively in the Clinician Executive Medicine curriculum?

13. What kind of setting/hospital/community do you see yourself practicing in the future? Why?

14. What do you think are the specific characteristics of a community that might influence how and where you may practice medicine someday?

15. What do you hope to gain from involvement with the Clinician Executive Medicine program?

16. What leadership roles have you held previously?

Since space in the CEMED program is limited, early application is encouraged. Note: personal interview will be required during “Second Look” day in April.

Note: The screen will go blank when the application is submitted.

CEMED Application

This h2 tag would be supplied by the skin.

CEMED Application

1. First Name

2. Middle Initial

3. Last Name

4. AAMC ID#

5. Current Address

6. City

7. State

8. Zip

9. Current Telephone #

10. Email Address answer must be an email address

11. Other than English, what languages are you proficient in?

12. What experiences, skills or attitudes do you have that would allow you to learn and contribute effectively in the Clinician Executive Medicine curriculum?

13. What kind of setting/hospital/community do you see yourself practicing in the future? Why?

14. What do you think are the specific characteristics of a community that might influence how and where you may practice medicine someday?

15. What do you hope to gain from involvement with the Clinician Executive Medicine program?

16. What leadership roles have you held previously?