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AHEC/OHSU Physician Assistant Mentorship Program
Request for Information Form

Please complete this form, print it, and either fax or send it to the address below.

Please send me # information packet(s) about the PA mentorship Program.

Name:               
Phone Number: 
Address:           
                        

List the rural communities in eastern Oregon where you have lived:

Please PRINT and fax or Mail to:
Northeast Oregon AHEC
One University Blvd
La Grande, OR 97850
541-962-3801 * 541-962-3416 fax

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