WELCOME TO CHICAGO CLERKSHIPS

CHICAGO CLERKSHIPS APPLICATION

* Indicates Response Required

Please fill in your name and address EXACTLY how you will want it to appear on official documents.

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Postal Code

* Country

* Phone

* Email Address:

* Citizenship:

* Do you have a visa?:

Yes

Not yet

* Name of University/Medical School:

* Exact Address of University/Medical School:

* I am:

A Foreign Medical Student

* University/Medical School start date:

Year th Are you in your internship year? Yes No

An International Medical Graduate

* University/Medical School start date:

* University/Medical School graduation date:

*ECFMG Number:
(If you do not have this number, you can establish an account at www.ecfmg.org.)

* I am interested in the following 3 rotations (please rank 1 to 3, 1 = top preference)

	Family Medicine
	Internal Medicine
	Cardiology
	Pediatrics
	Psychiatry
	Endocrinology
	Pulmonology
	Emergency Medicine
	Orthopedics
	Radiology
	Oncology
	Surgery
	Gastroenterology
	OB/GYN
	Pathology
	Urology
	Sports Medicine
	Neurology
	Anesthesiology
	Other

*Please review our facebook page for updates and provide additional information regarding your preferences here:

* I am applying for:

*Please provide additional detailed information regarding your preferences here:

* I would like to begin my clinical placement on:

*I am also requesting:

Homestay Placement

Airport Pick Up

Neither, only clinical rotation

Please attach your documents. 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 proof of immunity to Hepatitis B.

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*Please attach proof of immunity to measles, mumps and rubella (MMR).

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*Please attach proof of recent physical exam (within 12 months).

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*Please attach proof of PPD (within 6 months) or Chest Xray (within 12 months).

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*Please attach medical school diploma or transcripts (graduates) or letter of good standing (current students).

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* Please confirm the following requirements:

I understand that upon receiving my placement offer and details, I must pay a $200 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 I must present all documentation requested before my placement commences.

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), and current PPD report (within 12 months) .

SUPPORTIVE SERVICES

Orientation and Training
Career Counseling
Resume Critique
Clinical Evaluation
Letters of Recommendation
Homestay Placement
Airport Pickup

Downloadable Webinars, only $10! Click on the link to purchase and we will send you the link and any accompanying materials.
Preparing Your Personal Statement for ERAS
Preparing Your CV for ERAS

Visit our Chicago Clerkships BLOG.

HABLAMOS ESPAÑOL! Para comunicar con nuestra oficina en México, escribale al: mexico AROBA chicagoclerkships DOT com

MEDIV Education Consulting is the exclusive agent for Chicago Clerkships in China. Nationals of the PRC are encouraged to contact them before applying at www.mediv.com.cn.

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current and future externship placement.

Step 1:	Completed Score / Attempts Not yet completed
Step 2 CK:	Completed Score / Attempts Not yet completed
Step 2 CS:	Completed Score / Attempts Not yet completed
Step 3:	Completed Score / Attempts Not yet completed
*ECFMG Certified?:	Yes Not yet

CHICAGO CLERKSHIPS APPLICATION

SUPPORTIVE SERVICES

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