HSHPS is a private non-profit organization that represents Hispanic Serving Health Professions Schools in the U.S.

Instructions: Please type or print legibly. Please provide all information.

1) Applicant Information

Name:
Sex:
Social Security #:
Date of Birth:	/ / 19
U.S. Citizen:		Permanent Resident:
(If yes, please provide Alien Registration #)
Ethnicity:
Current Address:
City:
State:
Zip:
Permanent Address (if different than above):
City:
State:
Zip:
Telephone:
Mobile:
Fax:
E-mail:
Emergency Contact Name:
Phone:

2) Education and Training

Name of your Medical School/Public Health School:
Anticipated Degree:
Expected Graduation Date:
Address:
Other Degrees or Training:
Institution:
Degrees and Date Received:
Is your University a HSHPS member?
Areas of interest: