M4/Sub-Internship Elective Application

In order to process your application, the review committee will need in addition to this application:

• CV

• Photo

• USMLE Step 1 or COMLEX Level 1, 2 if available, first time pass score

***If CV, photo, and score(s) are not received after 30 days from date application received, application will be discarded.***

If approved, the department of Medical Education must receive the following prior to your start date:

• Letter stating you are a medical student in good standing who has been approved for this elective

• Proof of malpractice coverage by your medical school

• Health record

• Background check

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* 1. Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Preferred Name

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* 3. Date of Birth

Date of Birth

Date

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* 4. Gender

Female

Male

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* 5. Citizenship

US Citizen

Permanent Resident (Green Card)

H-1B

J-1

F-1

Other (please specify)

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* 6. 1st choice of dates for elective (4 weeks)

Start Date

Date

End Date

Date

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* 7. 2nd choice of dates for elective (4 weeks)

Start Date

Date

End Date

Date

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* 8. Medical School Information

Name of medical school

Degree

USMLE Step 1 or COMLEX Level 1 Score

Number of attempts to pass USMLE Step 1 or COMLEX Level 1

Tentative date of graduation (mm/yy)

My 4th year of medical school will begin/began (mm/yy)

Name of undergraduate school

Have you taken your USMLE Step 2 or COMLEX Level 2 (yes/no)

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* 9. Do you have transportation available?

Yes

None of the above

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* 10. Do you have a connection to the Canton area?

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* 11. What is your interest in women's health?

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* 12. List the 3 most important goals you have for this elective:

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* 13. Hobbies/Non-Professional interests:

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* 14. By typing my name below, I, the undersigned, agree to abide by the rules and regulations of Aultman Health System 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 like a PGY-1 resident 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.

I am in my fourth year of medical school or will be by the first day of my elective at Aultman Hospital and in good standing.

To be eligible for an invitation to interview for residency, individuals must meet all requirements listed below:
• A first-time pass on USMLE Step 1 or COMLEX Level 1 and a first-time pass on USMLE Step 2 with a minimum score of 220 or COMLEX Level 2 with a minimum score of 500. If you have taken both USMLE and COMLEX, you must meet the requirements for both.
• ECFMG certification is not required when applying.
• Core clinical clerkship experience in United States.
• May apply up to two years from medical school graduation, having been engaged in medical education through research or another academic experience during the gap.
• Institutional policy prohibits hiring new employees who smoke or use nicotine products.

In order to process your application, the review committee will need in addition to this application:
• CV
• Photo
• USMLE Step 1 or COMLEX Level 1, 2 if available, first time pass score
If CV, photo, and score(s) are not received after 30 days from date application received, application will be discarded.

If approved, the department of Medical Education must receive the following prior to your start date:
• Letter stating you are a medical student in good standing who has been approved for this elective
• Proof of malpractice coverage by your medical school
• Health record
• Background check

Send me a copy of my responses via email