FSA Selection Form Internal Medicine FSA Selection Form Name* First Last Email*Expected year of graduation?*Degrees Expected on Graduation- MD/PHD, MBA, MPH, JDWhat, if any, regions of the country are you specifically interested in for residency training?If you have communicated with an Internal Medicine faculty about being your FSA, please indicate who:Do you have a request for a specific IM faculty member to be your FSA and if so who?Do you have an internal medical specialty you are interest in pursuing fellowship in and if so, what specialty?Are you interested in a internal medicine primary care residency?Are you couples matching?Wil you require a VISA during residency training?*Please indicate if your STEP 1 score was < 210 and/or your STEP 2 score < 220, or if you failed any STEP testIs there anything else you would like us to know at this point?