Requested Date (Four-Week Clerkship) *
Requested Date (Four-Week Clerkship)
Please indicate your desired start date for a four-week clerkship.
Second Choice Date (Four-Weeks) *
Second Choice Date (Four-Weeks)
Please indicate your second choice for a start date.
Name *
Name
Address *
Address
Phone - Home *
Phone - Home
Phone - Cell *
Phone - Cell
Medical School
Medical School
Expected Date of Graduation *
Expected Date of Graduation
Name of Chairman, Department of Family Medicine *
Name of Chairman, Department of Family Medicine
When you have completed this form, please send via email a current curriculum vitae, current transcripts, and Step 1/COMLEX scores to SVrbka@LMEP.com.