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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
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