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Application for Acceptance to the Resident Rotation Program
Date Submitted
*
PERSONAL DATA
Name First * Middle * Last *  
Gender* male                 Female Telephone *
Birthdate
Fax
Nationality E-mail *
Present Address Street *
City *
State/Province *
Postal Code *
Country *
PROGRAM INFORMATION  
Preferred Specialty Duration (weeks)
1. * *
2.
3.

All students must stay a minimum of two weeks in any chosen specialty excepting Traditional Chinese Medicine, which is limited to one week total study due to the department’s capacity. (SRRSH does not have pediatrics. If you choose internal Medicine, inform us of the desired subspecialty)

Requested Starting Date Ending Date Total Duration (weeks)
EDUCATION RECORD Please complete information relevant to your education
Dates     Institution Degrees and Honors
Month and Year     College/University  
* to * * *
to
Month and Year     Graduate School  
to
Month and Year     Medical School  
to
to Internship 
      Location    
to Residency 
      Location    
Please state the learning objectives of your elective:
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