STATEMENT OF PERSONAL DATA

Photo of student talking with AHEC member

STATEMENT OF PERSONAL DATA

DC Area Health Education Center

First Name:

Last Name:

SSN:*

Date of Birth:

Sex:

M F

Citizen of:

VISA Status:

Home Address:

Home City:

State:

Zip:

Home Country:

Home Phone:

Office Address:

Office City:

State:

Zip:

Office Country:

Office Phone:

Electronic Mail:

Marital Status:

Single Married
Divorced Widowed

Spouse/Partner's Name:

Ethnicity (Optional) -
Please mark all that apply

American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White / Caucasian
Other

Veterans Status (Optional):

Vietnam Era Veteran Disabled Veteran

Educational Background

Degree(s)	Held	Date Awarded	School \| Institution




Phi Beta Kappa Alpha Omega Alpha

Academic Positions Held

Dates	Rank	School \| Institution	Status (Full or Part-Time)

* this information is not being sent over a secure server. If you would prefer, you can call our program assistant 202.994.7669 with this information.

If you need to fax this or send via US Mail, it should be addressed to:

DC AHEC Program Office
900 23rd St. NW
#6188
Washington DC 20037
202-994-7669 (voicemail)
202-994-2636 (fax)