Externship Application Form for Medical Graduates

Personal Information
Full name (as on Passport):

Gender:

Male

Female

Date of Birth:

Permanent Address:

Mailing Address:

Email Address:

Phone Number:

Emergency Contact:

(Include Name, relationship, phone number, and address

in the USA)

Medical Education
Medical School:
Year of Graduation:
Degree Earned:

Externship Details:
Specialty Preference: (specialties you are interested in)
1)
2)
3)
Preferred dates of your rotation: (we cannot guarantee youll get your requested
dates, however we will try to match it as closely as possible):

Visa and Citizenship Details:

Country of Citizenship:
Passport Number:
Passport Expiry Date:

Visa Status:
Visa Expiry date:

Other Documents:
1) A complete CV mentioning your professional accomplishments, publications,
and education until now.
2) A copy of Official Transcripts from your medical school (in English).
3) Copy of Medical Diploma.
4) Passport copy (ID Page, and Visa copy).
5) ECFMG status, or at least 1 USMLE Exam score report, or ECFMG Credential
Verification Service. We use this to verify your identity and confirm that you
have graduated from an IMED listed medical school.

6) The cost of the clinical externship will not exceed $1725.00.

I certify that this information is true to the best of my knowledge:
Name:
Date: