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MyERAS Worksheet (ERAS 2016)

This worksheet may be printed and used to bein !omp"etin your MyERAS app"i!ation o#$"ine%A"" re&uired 'e"ds are hih"ihted p"ease note that some o* 'e"ds are re&uired on"y in !ertain!ir!umstan!es%

+ersona" ,n*ormation

-onta!t ,n*ormation

.irst /ame AMA/ +re*erred +hone

Midd"e /ame Mobi"e +hone

ast /ame +TA A"ternate +hone

+re3ious ast /ame .a4

Su54 +aer

+re*erred /ame Emai"

ast diits o* SS/

Address

-urrent Mai"in Address

Address 1

Address

2

-ountry

State (Required for U.S. & Canadian addres

-ity

+osta" -ode

,s your permanent address the same as your !urrent mai"in address7 8es /o

+ermanent Address

Address 1

Address

2

-ountry

State

-ity

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+osta"

-ode

+hone

-iti9enship ,n*ormation

Are you a %S% !iti9en7 8es/o

,* yes are you a !iti9en o* a !ountry in addition to the nited States7 8es /o

,* yes se"e!t your !ountry o* dua" !iti9enship (other than the

nited States): ,* you are not a %S% !iti9en se"e!t !iti9enship

status:

,* you are a .orein /ationa" !urrent"y in in the %S% with ;a"id ;isa Status se"e!t your!urrent ;isa$1?) in orderto parti!ipate in %S%

residen!y and

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,* app"i!ab"e p"ease indi!ate your state or pro3in!e o* residen!e in the nited States or -anada:

Mat!h ,n*ormation

@ 201 AAM-% May not be reprodu!ed without permission% +ae 2

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/RM+ Mat!h

I plan to participate in the NRMP match? Yes No

If yes, NRMP ID

Participating as a couple in NRMP: Yes No

If yes, Partner's Name:

Specialties Partner is applying to:

/MS Mat!h

I plan to participate in the NMS match? Yes No

If yes, AA Match Num!er "NMS Num!er#:

Participating as a couple in the NMS: Yes No

If yes, Partner's Name:

Specialties Partner is applying to:

ro"oy Mat!h

A$A Mem!er Num!er:

Additiona" ,n*ormation

SME

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enera"

ender ?irth +"a!e ?irth Cate

Se"* ,denti'!ation

,* you reside in the European nion do not answer this &uestion% +"ease inore this se!tion%

This se!tion a""ows you to indi!ate how you se"*$identi*y% When se"e!tin FDtherF as a sub$!ateory the te4t 'e"d is

"imited to 120 !hara!ters but is not re&uired 'e"d% ,* you pre*er not to se"*$identi*y p"easeinore this se!tion%

>ow do you se"*$identi*y7 +"ease se"e!t a"" that app"y%

>ispani! atino or o* Spanish oriin

-o"ombian

Arentinea

n

-uban

Comini!anMe4i!anispani!:

Ameri!an ,ndian or A"askan

/ati3e

Triba" a5"iation:

Asian

?an"adeshi Gorean

-ambodian aotian

-hinese +akistani

.i"ipino Taiwanese

,ndian ;ietnamese

,ndonesian Dther Asian:

=apanese

?"a!k or A*ri!anAmeri!an

A*ri!an Ameri!an

A*ro$

-aribbean

A*ri!an

Dther ?"a!k:

/ati3e >awaiian or +a!i'!

,s"ander

uamanian

/ati3e

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>awaiianSamoan

Dther +a!i'!

,s"ander:

White

Dther:

anuae ."uen!y

@ 201 AAM-% May not be reprodu!ed without permission% +ae

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What "anuaes do you speak7 Se"e!t a"" that app"y% .or ea!h "anuae that you se"e!in!"udin En"ish you wi"" be asked to rate your pro'!ien!y in that "anuae usin thuide"ines pro3ided be"ow%

/ati3eebrew /orweian Te"uu

?ena"i >indi +atois Thai

?u"arian >mon +ennsy"3ania Cut!h Tonan

?urmese >unarian +ersian Turkish

-aHun ,"o!ano +o"ish krainian

-hinese ,ndonesian +ortuuese rdu

-roatian ,ta"ian +unHabi ;ietnamese

-ushite =apanese Romanian 8iddish

-9e!h Gannada Russian

Canish Gorean Samoan

Cut!h Gru "bo 8oruba Serbian

En"ish aotian Serbo!roatian

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.innish ithuanian S"o3ak

.ormosan Ma"aya"am Spanish

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Are you !ommitted to *u"'"" a %S% mi"itary a!ti3e duty ser3i!e ob"iations

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>iher Edu!ation

This se!tion a""ows mu"tip"e entries *or ea!h nderraduate and raduate S!hoo" you ha3e atta!he

Sin!e most non$%S% edu!ationa" systems do not *o""ow the %S% mode" a"most a"" students and

raduates o* internationa" medi!a" s!hoo"s wi"" indi!ate F/oneF%

/one

Entry 1

,nstitutio

n

o!ation

Edu!ation

Type

.ie"d o* Study

Ceree e4pe!ted or earned

Cates o* Attendan!e: .rom Month .rom 8ear To Month To 8ear

Entry 2

,nstitutio

n

o!ation

Edu!ation

Type

.ie"d o* Study

Ceree e4pe!ted or earned

Cates o* Attendan!e: .rom Month .rom 8ear To Month To 8ear

Medi!a" Edu!ation

@ 201 AAM-% May not be reprodu!ed without permission% +ae B

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This se!tion a""ows entries *or ea!h Medi!a" S!hoo" you ha3e attended%

Entry 1

-ountry

,nstitutio

n

Ceree

Ceree Month Ceree 8ear

Cates o* Edu!ation: .rom Month .rom 8ear To Month To 8ear

Entry 2

-ountry

,nstitutio

n

Ceree

Ceree Month Ceree 8ear

Cates o* Edu!ation: .rom Month .rom 8ear To Month To 8ear

Additiona" ,n*ormation

Membership in>onorary