4th Year Elective Application

Name

First Last

Nickname

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email Address

Date of Birth

Place of Birth

SSN: last 4 digits

Personal Insurance

Yes
No

Company

Malpractice Insurance

Yes
No

Company

Emergency Contact

Relationship

Phone

Education Information

High School

Premedical College

Location

Degree

Year Completed

Medical College

Location

Degree

Expected Date of Graduation

Honors/Activities

Elective Information

Please apply a minimum of 6 months prior to request.

Please tell us what your first date choice is.

Please tell us what your second date choice is.

Please tell us what your third date choice is.

Please indicate the rotation you desire.

Ambulatory Track
Sub-Internship Track
Osteopathic Manipulative Track

Please tell us how many weeks of the following basic core clerkships you will have successfully completed prior to the beginning of the elective rotation requested.

Family Medicine

Surgery

OB/GYN

Pediatrics

Psychiatry

Medicine

What are your future career plans (specialty, type of practice, and/or other professional goals)?

Why are you interested in rotating at MDFMR?

Are you planning to interview with the FM Residency if invited to do so during Recruitment Season?

Yes
No

What are your ties to Maine or the Northeast?

If you are applying for an Osteopathic Manipulative Track, can you give a history on your exposure to OMM?

How did you hear about our program?

Please let us know if you have specifically spoken to our faculty, residents, or students.

Do you plan to stay in the housing provided for students at the cost of $50.00/week? Please note that our housing can only accommodate the rotating student - family/pets are not allowed.

Yes
No

Because of great interest in the MDFMR Medical Student Elective Program, we require a completed application and all supporting documents including a copy of your immunization records, transcript, Step One scores, current background check (within a year of your requested rotation) with no adverse findings, and a letter from your school stating you are a current student in good standing and will be covered by malpractice insurance during your rotation (with a copy of the certificate). Please mail, e-mail, or fax these documents to the program coordinator once you submit this online application. Only completed applications will be considered. Thank you for your interest in our program!

Medical Student Elective Rotation Application

Education Information

Elective Information

Please tell us how many weeks of the following basic core clerkships you will have successfully completed prior to the beginning of the elective rotation requested.