Application for Medical Student Electives

(Please allow three weeks to process. Do not call the office for status.)
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: Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming ZIP:	Permanent State: Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming 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