APPROVED:_________________________________Dr. Gill  
APPROVED:___________________________Carol Young

In order to process your application, the program director will need:
• this application
• copy of USMLE (minimum 200)/COMLEX (minimum 450) first time pass Step/Level 1 score
• CV

If approved, the department of medical education must receive prior to your start date:
• letter stating you are a medical student in good standing who has been approved for this M4/sub-internship elective
• proof of malpractice coverage by your medical school
• health record
• background check

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* 1. Full Name

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* 2. Date of Birth

Date / Time

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* 3. Gender

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* 4. Email Address

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* 5. Address

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* 6. City, State, and Zip

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* 7. Phone

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* 8. Pager

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* 9. Citizenship

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* 10. First choice of requested dates for M4/sub-internship elective

Start Date
End Date

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* 11. Second choice of requested dates for M4/sub-internship elective

Start Date
End Date

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* 12. Medical School

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* 13. Do you have transportation available?

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* 14. What is your connection to the Canton area?

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* 15. What is your interest in woman's health?

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* 16. By typing my name below, I, the undersigned, agree to abide by the rules and regulations of Aultman Hospital and their applicable policies and procedures while rotating at Aultman Hospital. I hereby certify that the above information is correct. 

I understand I will be working hours similar to a PGY-1 in accordance with ACGME Clinical Work and Education Hours for a total of four weeks.  I will request time off prior to the start of my elective.   

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