Secondary Application Form Contact Information * Your First Name Your Middle Initial * Your Last Name * Address 1 Address 2 * City State/Province AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingDistrict of Columbia * Postal Code * Country ArubaAfghanistanAngolaAlbaniaAndorraUnited Arab EmiratesArgentinaArmeniaAmerican SamoaAntigua and BarbudaAustraliaAustriaAzerbaijanBurundiBelgiumBeninBurkina FasoBangladeshBulgariaBahrainBahamasBosnia and HerzegovinaBelarusBelizeBermudaBolivia, Plurinational State ofBrazilBarbadosBrunei DarussalamBhutanBotswanaCentral African RepublicCanadaSwitzerlandChileChinaCôte 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HerzegovinaBelarusBelizeBermudaBolivia, Plurinational State ofBrazilBarbadosBrunei DarussalamBhutanBotswanaCentral African RepublicCanadaSwitzerlandChileChinaCôte d'IvoireCameroonCongo, Democratic Republic of theCongoCook IslandsColombiaComorosCabo VerdeCosta RicaCubaCayman IslandsCyprusCzechiaGermanyDjiboutiDominicaDenmarkDominican RepublicAlgeriaEcuadorEgyptEritreaSpainEstoniaEthiopiaFinlandFijiFranceMicronesia, Federated States ofGabonUnited Kingdom of Great Britain and Northern IrelandGeorgiaGhanaGuineaGambiaGuinea-BissauEquatorial GuineaGreeceGrenadaGuatemalaGuamGuyanaHong KongHondurasCroatiaHaitiHungaryIndonesiaIndiaIrelandIran, Islamic Republic ofIraqIcelandIsraelItalyJamaicaJordanJapanKazakhstanKenyaKyrgyzstanCambodiaKiribatiSaint Kitts and NevisKorea, Republic ofKuwaitLao People's Democratic RepublicLebanonLiberiaLibyaSaint LuciaLiechtensteinSri LankaLesothoLithuaniaLuxembourgLatviaMoroccoMonacoMoldova, Republic ofMadagascarMaldivesMexicoMarshall IslandsNorth MacedoniaMaliMaltaMyanmarMontenegroMongoliaMozambiqueMauritaniaMauritiusMalawiMalaysiaNamibiaNigerNigeriaNicaraguaNetherlands, Kingdom of theNorwayNepalNauruNew ZealandOmanPakistanPanamaPeruPhilippinesPalauPapua New GuineaPolandPuerto RicoKorea, Democratic People's Republic ofPortugalParaguayPalestine, State ofQatarRomaniaRussian FederationRwandaSaudi ArabiaSudanSenegalSingaporeSolomon IslandsSierra LeoneEl SalvadorSan MarinoSomaliaSerbiaSouth SudanSao Tome and PrincipeSurinameSlovakiaSloveniaSwedenEswatiniSeychellesSyrian Arab RepublicChadTogoThailandTajikistanTurkmenistanTimor-LesteTongaTrinidad and TobagoTunisiaTürkiyeTuvaluTaiwan, Province of ChinaTanzania, United Republic ofUgandaUkraineUruguayUnited States of AmericaUzbekistanSaint Vincent and the GrenadinesVenezuela, Bolivarian Republic ofVirgin Islands, BritishVirgin Islands, U.S.Viet NamVanuatuSamoaYemenSouth AfricaZambiaZimbabwe * Do you have a visa?: —Please choose an option—I'm an American citizen.I'm a legal resident.I have a visa.I will need a visa. * How did you hear about International Clinical Clerkships? * Name of University/Medical School: %D Radiology: Oncology: Surgery: Gastroenterology: OB/GYN: Pathology: Urology: Sports Medicine: Neurology: Anesthesiology: Other Specialty Name: : Other Specialty Rank * I am applying for: —Please choose an option—ClerkshipExternshipOther * If clerkship: —Please choose an option—4 weeks of one specialty8 weeks of one specialtyTwo 4 week rotations in two specialtiesOtherApplying for Externship * If externship: —Please choose an option—3 months6 months12 monthsOtherApplying for Clerkship Please provide additional detailed information regarding your preferences here: * I would like to begin my clinical placement on: *I am also requesting: —Please choose an option—Homestay PlacementAirport Pick UpNeither, only clinical rotation Document Uploads * Please attach your documents in PDF or MS-Word Doc compatible formats. *A maximum of 1000 kb is allowed for each file. *Please attach a scan of the photo page of your passport (or state ID for US residents) here. *Please attach your CV/resume here. *Please attach letter of good standing with your local police department (within 6 months). *Please attach proof of immunity to Hepatitis B. *Please attach proof of immunity to measles, mumps and rubella (MMR). *Please attach proof of recent physical exam (within 12 months). *Please attach proof of PPD (within 6 months) or Chest Xray (within 12 months). *Please attach medical school diploma or transcripts (graduates) or letter of good standing (current students). Required Acknowledgments * Please confirm the following requirements: I understand that upon receiving my placement offer and details, I must pay a nun-refundable $300 deposit to secure my placement. I understand that all fees must be paid IN FULL at the time of my placement commences. I understand that all this application will not be processed until confirmation of the application fee. I understand that rotation, clerkship, and externship is based upon availability; if there is a wait, you will be provided with alternative available options that may not be in the areas of your preferred ranking. I understand that housing options is based upon availability; if there is a wait, you will be provided with alternative available options. I understand that rotation, clerkship, experience options and housing is based upon availability; if there is a wait, you will be provided with options I understand that I must present all documentation requested before my placement can be arranged (USMLE score reports (if available), letter of good standing or diploma/transcript from school, proof of immunization (Hep B, MMR, DTP placement_details] I understand that upon receiving my placement offer and details, I must pay a nun-refundable $300 deposit to secure my placement. I understand that all fees must be paid IN FULL at the time of my placement commences. I understand that all this application will not be processed ul Clerkships