You will be able to identify specific position(s) that you wish to be considered for later on this form. The positions that are available should correspond to those listed on the Rural Health Service Corps website. If necessary, you may leave additional comments in the space provided at the end of the application. If you have questions, please contact the RHSC program staff using the information listed under "contact us" on the RHSC web site: www.ruralhealthservicecorps.org

Your Contact Information:

Eligibility and Availability

Time Frame for Service

Area(s) of Interest 

Experience

References - Please provide three professional references

"This program is available to all, without regard to race, color, national origin, disability, age, sex, political affiliation, or, in  most instances, religion."

Electronic Signature Statement

I understand that submission of this Rural Health Service Corps Application constitutes affixation of my electronic signature.  I verify that the information on this application accurately represents my candidacy and is true to the best of my knowledge.

In the event of my active candidacy in the program, I authorize the Rural Health Network of South Central New York and the Rural Health Service Corps program staff to investigate any statement contained in this application, and to conduct necessary reference and criminal background checks to determine my qualification.