Special Family Medicine Student Online Elective Application

Exit Survey

Questions marked with a * are required

100%

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.Yes

Contact Information

Phone Number

First Name

Last Name

Middle Name

Street Address

City

State

Zip Code

Email Address

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

First Attempt

USMLE Step II Score

Check this box if you passed USMLE Step II on 1st Attempt

First Attempt

COMLEX 1 Score

Check this box if you passed COMLEX 1 on 1st Attempt

First Attempt

COMLEX 2 Score

Check this box if you passed COMLEX 2 on 1st Attempt

First 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