Preview the Application Questions
Kathelen and Dan Amos Medical Student Loan Forgiveness Program
Improving Access to Primary Care in Georgia
Personal Details
Name
Gender identity
Race and Ethnicity
Current mailing address
Permanent mailing address
Phone and email address info
Medical Education
Medical school
Graduation year
Degree
Intended or current discipline(s) of primary practice: family medicine, geriatrics, internal medicine, pediatrics, other
Educational Debt
Anticipated/Outstanding Debt
Undergraduate educational debt
Medical educational debt
Other educational debt
Paid Debt
Undergraduate educational debt
Medical educational debt
Other educational debt
Training
Residency*
Residency Program & year of completion
City/State
Residency Program Type (IM, FM, Peds, Geri, or other)
City/State
Residency Program Type (IM, FM, Peds, Geri, or other)
Additional Training Post-residency**
Program
Year of completion
City
State
Description (e.g. This program is a Geriatrics fellowship, or this program is HIV training that involves practicing primary care with HIV population)
Year of completion
City
State
Description (e.g. This program is a Geriatrics fellowship, or this program is HIV training that involves practicing primary care with HIV population)
Practice**
NPI Number
Would you need a visa sponsor to start practicing primary care in Georgia?
Practice details (moving to a new location, have a signed letter with a practice in GA, currently practicing in GA, planning to stay in GA
Practice location (St address, city, state, zip code, county)
Would you need a visa sponsor to start practicing primary care in Georgia?
Practice details (moving to a new location, have a signed letter with a practice in GA, currently practicing in GA, planning to stay in GA
Practice location (St address, city, state, zip code, county)
*not applicable for MS1-3 and most MS4s
**not applicable for MS1-4 and most current residents
Personal Statement
It is acceptable to adapt an AMCAS, ERAS, or similar essay for this application.
Explain why you have a passion for primary care. Your response should incorporate, in no particular order, (1) a reflection on the experiences or people in your life that have influenced your decision to pursue primary care, (2) future plans for your medical career, and (3) two or three selection criteria that apply to your current circumstances or future plans.
Explain why you have a passion for primary care. Your response should incorporate, in no particular order, (1) a reflection on the experiences or people in your life that have influenced your decision to pursue primary care, (2) future plans for your medical career, and (3) two or three selection criteria that apply to your current circumstances or future plans.
Resume or CV
Provide a resume or CV document in pdf form. For additional guidance, we recommend the official SOM promotion templates provided for faculty development.