Special Family Medicine Student Online Elective Application
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Demographic Information
Today's Date
Interested in our Family Medicine Residency?
Check this box if you plan to apply for our Family Medicine Residency Program.
Contact Information
Date of Birth
Citizenship
Citizenship (Citizenship Country and Visa Status if not a US Citizen. We do not sponsor visas for medical students.)
Medical School Education
Medical School Name
Medical School City, State, and Country
Anticipated Graduation Date
Type of Degree (DO, MD, MBBS, etc.)
USMLE Step I Score
Check this box if you passed USMLE Step I on 1st Attempt
USMLE Step II Score
Check this box if you passed USMLE Step II on 1st Attempt
COMLEX 1 Score
Check this box if you passed COMLEX 1 on 1st Attempt
COMLEX 2 Score
Check this box if you passed COMLEX 2 on 1st Attempt
Requested Elective Information
How many Family Medicine electives are you requesting? (Three 4-week rotations are the maximum # that can be approved in total at the Chattanooga Campus.)
Course Names/Numbers/Descriptions
Name and Course # of 1st Choice Elective
Name and Course # of 2nd Choice Elective
Name and Course # of 3rd Choice Elective
Requested Block Dates – We prefer that you request the same dates as our UT Student Block Dates but will consider other dates if available.
1st Choice Beginning Date
1st Choice Ending Date
2nd Choice Beginning Date
2nd Choice Ending Date
3rd Choice Beginning Date
3rd Choice Ending Date
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