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Preferred time to reach you during the day: (time:
to
) evening: (time:
to
)
If you will be traveling during the months of
November-February (holiday, clinical rotations, other residency interviews,
etc.), please provide approximate dates of travel and the suggested way to
reach you during these periods:
Travel Log (please
complete the following for each travel destination for which housing
is requested)
What are your dates in HOST interview
city?
Arrival (mm/dd/yy)
Departure (mm/dd/yy)
What date(s) will you need overnight
lodging? (mm/dd/yy)
What is the date of your interview and
which medical center or residency program are you interviewing with
during this trip? Date of Interview
(mm/dd/yy):
Medical Center/Residency Program:
Where is it located? (if
not a major city, what is the nearest city?)
State:
Specialty for which you are
interviewing?
Will your spouse/significant other be
accompanying you? (not all hosts are able to accommodate)
yes
no
if possible
Any other comments you wish to add
(special needs - i.e. smoking preference, allergies to household pets,
etc.):
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