| Last
Name |
|
| First
Name: |
|
| E-mail: |
|
| Home address: |
|
| City: |
State:
Zip:
|
| Phone
Number: |
|
| Citizenship: |
|
| Birthdate: |
19
|
| Sex: |
Male
Female |
Ethnicity: |
*If you selected other from above please specify |
| Social
Security Number: |
|
| Home
school: |
|
List your choices in order of preference. Indicate the name, number, and period for each elective. Give alternatives if possible. If you desire a 2-week clerkship, please handwrite it on this form. Indicate whether you want the "Section A" (first two weeks) or "Section B" (second two weeks) of the clerkship. If it is not specified, you will be assigned to either section or both, depending on availability.
|
Summer Quarter
|
(Periods 1, 2, 3): Application Acceptance Period: April 1st to
April 30th
|
| First
choice: |
Clerkship
during
|
| Second
choice: |
Clerkship
during
|
| Third
choice: |
Clerkship
during
|
| Fourth
choice: |
Clerkship
during
|
| Fifth
choice: |
Clerkship
during
|
|
Total
number of desired Summer clerkships:
|
Autumn Quarter
|
(Periods 4, 5, 6): Application Acceptance Period: July 1st to
July 31st
|
| First
choice: |
Clerkship
during
|
| Second
choice: |
Clerkship
during
|
| Third
choice: |
Clerkship
during
|
| Fourth
choice: |
Clerkship
during
|
| Fifth
choice: |
Clerkship
during
|
|
Total
number of desired Autumn clerkships:
|
Winter Quarter
|
(Periods 7, 8, 9): Application Acceptance Period: October 1st
to October 31st
|
| First
choice: |
Clerkship
during
|
| Second
choice: |
Clerkship
during
|
| Third
choice: |
Clerkship
during
|
| Fourth
choice: |
Clerkship
during
|
| Fifth
choice: |
Clerkship
during
|
|
Total
number of desired Winter clerkships:
|
Spring Quarter
|
(Periods 10, 11, 12): Application Acceptance Period: January
1st to January 31st
|
| First
choice: |
Clerkship
during
|
| Second
choice: |
Clerkship
during
|
| Third
choice: |
Clerkship
during
|
| Fourth
choice: |
Clerkship
during
|
| Fifth
choice: |
Clerkship
during
|
|
Total
number of desired Spring clerkships:
|
|
Please print this page and
send it along with all supporting documentation by mail to:
Office of Medical Student Affairs
Stanford University School of Medicine
1265 Welch Road, MSOB X1C48
Stanford, CA 94305-5404
|