M3 Clerkships - Emergency Medicine Student Elective

Questions marked with a * are required

100%

Demographic Information

Today's Date

Phone where you can be reached:

Do you plan to apply to our Emergency Medicine Residency?

Yes

No

Contact Information

Last Name

First Name

Middle Name

Street Address

City

State

Zip Code

Email Address

What is your date of birth?

Birthplace (City, State, Country)

Citizenship

Undergraduate Education

Undergraduate University

Degree(s) Awarded

Graduation Date

Medical School Education

Medical School

Location (City, State, Country)

Anticipated Graduation Date

USMLE Step I Score

USMLE Step II Score (if available)

Requested Elective Information

Check if you have already applied for this elective via VSAS.

Yes

No

Check if you will be applying via VSAS in the next week.

Yes

No

Check if you have submitted your medical school transcript via VSAS.

Yes

No

Check if you are an osteopathic student and are also submitting the pdf application.

Yes

No

Check if you are an international student and are also submitting the pdf application.

Yes

No

If you checked one of the previous 2 boxes, check here if you will be emailing or faxing your transcript to [email protected], 423.778.7677. We must receive this to complete your application.

Yes

No

Requested Elective Dates

We do not approve students outside the UT block dates.

1st Choice Beginning Date

1st Choice Ending Date

2nd Choice Beginning Date

2nd Choice Ending Date

3rd Choice Beginning Date

3rd Choice Ending Date

UTHSC College of Medicine, Chattanooga | 960 East Third Street, Suite 100, Chattanooga, TN 37403 | 800.947.7823 ext. 6956

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