Name: 
       Email: 
Home Address: 
  Home Phone:  
Office Phone: 
   Specialty: 
Type of Practice: 
Place of Residency: 
Hospital Affiliation: 
      Marital Status: Married Single Divorced Widowed
Children at Home: Yes NO
    Graduation Year: 

1. Would you be willing to provide complimentary housing to a fourth
year medical student interviewing for residency positions in your area?
YES NO

2. Would you be willing to discuss your medical specialty and provide
geographic information relative to the interview site?
(Check all that apply)
YES-By Email
YES-By Telephone
YES-By Mail
NO

3. How many days would you be willing to extend your
services per visit?

4. How many people would you be willing to accommodate
per visit?

5. How often would you be willing to accommodate students
during a school year?

6. Would you be willing to provide transportation to the interview?
From the airport? From the train station?

If not, is public transportation available in your area?
YES NO

7. Do you prefer male or female students?
MALE FEMALE EITHER

8. Do you have any pets?
If so, please specify type.

9. Are there any special restrictions?
ie. smoking policy, dietary, etc.

Please notify the MAA at (410) 706-7454 immediately regarding problems or concerns or if you would like to have your name removed from the list at any time. We want your feedback and appreciate your comments. Be advised that the information you have provided is held exclusively at the alumni office. If you prefer, you may return this form to 522 W Lombard St, Baltimore MD 21201 or Fax to 410-706-3658 to activate your participation in the HOST program..