SIU School of Medicine

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Office of Student Affairs

AUTOBIOGRAPHICAL FORM

This form is used in medical student performance evaluations. It will be included in your academic "red" file. You may update this form as needed or additional information may be added at the time of your medical student performance evaluation appointment with Dr. Constance.

* Denotes Required Fields

Enter dates in the mm/dd/yyyy format.

If a field requiring entry does not apply to you, enter n/a for not applicable.


STUDENT INFORMATION:
*First Name
*Last Name

PREMEDICAL BACKGROUND:
*Undergraduate college or university name: *Major:
Honors: (i.e., cum laude) *Degree: *Date Received Degree:

 
Graduate college or university name: Field of Study:
Degree: Date Received Degree:

If you did not enter medical school immediately after completion of your previous degree(s), briefly describe your activities during the interim:

MEDICAL SCHOOL ACTIVITIES:

Extracurricular activities, awards, class offices, membership of committees:

Research activities:

Voluntary service:

TRAINING AND CAREER PLANS: