North Carolina AHEC Housing Request


Please read the housing guidelines before completing this form.  Complete all sections unless this form is being submitted along with the NC AHEC Community Primary Care Rotation form.  Then it is only necessary to complete shaded areas.  Click on the Submit form button to submit to Greensboro AHEC.

  I have read and agree to the housing guidelines.
Date submitted to the AHEC indicated below Degree Sought 
Area L    Charlotte    Coastal    Eastern    Greensboro    Mountain    Northwest    
Southern Regional    Wake

Name Sex:Male  Female  SS# (last 4 digits)
Pres Address
City, State, Zip
Home Phone
Perm. Address
City, State, Zip
Home Phone
Age Pager # Email 
Drivers License #  License Tag #
Emerg. Contact Day Phone Eve Phone


University School Contact Fax

Department/School Phone Email


 

Submit additional form for Rotations 4+  

Rotation1

Course name or number
Rotation site
Rotation city
Preceptor name
Preceptor phone
Rotation start date
Rotation end date
Course name or number

Rotation 2

Rotation site
Rotation city
Preceptor name
Preceptor phone
Rotation start date
Course name or number

Rotation 3

Rotation site
Rotation city
Preceptor name
Preceptor phone
Rotation start date
Rotation end date
Rotation end date

 

Housing availability confirmed approximately 30 days prior to your rotation date.  See Housing Guidelines for AHEC specifics.

Housing arrival date
Housing departure date
Office use only


Copyright © 2005 [Greensboro AHEC]. All rights reserved.
Revised: