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Maimonides Medical Center Tina Marshall, Student Coordinator
Office of Academic Affairs
tmarshall@maimonidesmed.org

SECTION A


Submission Date:
Last Name:
First Name:

Present Address Permanent Address
Address:
Address:
City:
City:
Present State:
ZIP:
Permanent State:
ZIP:
Contact Telephone:
Telephone:
E-Mail:
Cell:

Medical College:
Graduation Date & Year:

Emergency Contact:
Relationship:
Telephone:
City/State:

Elective 1 in: From: To:
Elective 2 in: From: To:
Elective 3 in: From: To:




Medical Students: Please be informed that we require students to apply no more than 4-months in advance of the elective start date.  If your application is more than 4-months it will not be processed and you will have to resubmit within 4-months of the elective start date.  Thank you for your attention to this matter.  - Academic Affairs

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Maimonides Medical Center    |    4802 Tenth Avenue    |    Brooklyn, NY 11219    |    718.283.6000    |