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Student Program Questionnaire
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Student Program Questionnaire
Student Program Questionnaire
Step
1
of
5
- Personal Background
20%
About You
To get started, we're going to ask some personal information about you. You can track your progress with the bar at the top of this form, and can save and continue at any point. Let's get going!
Name
First
Last
Date of Birth
Month
Day
Year
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
Cell Phone
Other Phone
Family Information
Are you married?
Yes
No
Spouse Information
Spouse's Name
First
Last
Children Information
Do you have children?
Yes
No
Children's Information
Please list your children's name(s) and age(s):
Additional Family Information
What is your home town and state?
Great!
Next, we're going to ask a few questions about your education.
Education and Licensing
Tell us a little more about your education.
Name of Chiropractic College
Projected Month and year of graduation
What states are you interested in practicing in?
Moving on
The next section focuses on your post-college experiences.
Chiropractic Background
This section examines some of your post-college experience and future goals.
How did you hear about AMC?
What National Boards have you passed so far?
Why are you becoming a chiropractor?
Why are you applying with AMC Right Start?
What interests you about AMC? (check all that apply)
Student Program
Right Start Program
Financing
Leasing
Location/Market Help
Efficiency/System
Well Aligned/Advanced Functional Therapies
Associateship/IC/Practice Purchase Opportunities
Other
List names of clubs, fraternities, or sororities of which you are a member.
What chiropractic techniques are you planning to use?
Do you plan to use functional therapies?
Yes
No
What therapies do you plan to use?
You're doing great!
Next, we're going to ask about your plans for financing your practice. This information is kept strictly confidential.
Financial
All information is kept strictly private and confidential.
Do you need help with financing for your future practice?
Yes
No
Credit Score
In some cases we can help with credit repair and financing, but we do need to know your current credit score to see if you qualify.
What is your approximate credit score?
Minimum Credit Score
The SBA does have a minimum credit score of 675 for financial assistance. We can discuss the steps you may be able to take to reach that threshold.
All done with financials!
The next section helps us understand you as a person.
Summary
As before, there are no right or wrong answers to this section. These questions help us determine the best ways to help you reach your goals.
Do you tend to be more competitive or cooperative?
Competitive
Cooperative
Competitive people have what is called a Production Drive. They are inclined to be task-orientated. Cooperative people, on the other hand, have what is termed a Connection Drive—in other words, they tend to be people-oriented or people-centric.
Do you prefer constancy or change?
Constancy
Change
People who prefer constancy have what is referred to as a Stability Need—a desire for consistency, order, and routine. In contrast, people who prefer change have what is called a Variety Need; they are stimulated by new experiences and energized by change.
Which would make you feel more valued at work: sincere appreciation without financial bonus, or a bonus without appreciation?
Appreciation
Bonus
If you would rather have appreciation, you possess what is called an Internal Award system—one characterized by private recognition and contribution. If you would rather have the monetary bonus, you have what is called an External Award system—one characterized by public recognition and opportunity for advancement.
Would you be interested in an Advanced Associate position in a successful AMC office?
Yes
No
Fantastic!
All that's left is to hit the submit button below. We know that was a lot of work, but it will be worth it to start the journey to accomplishing your goals!
Name
This field is for validation purposes and should be left unchanged.
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