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Name:

 

Last

Middle

First

Sex:

Male  Female
Country of Origin: 1-Nigeria      2-Africa    3-Caribbean
Hospital/Practice Address:

Email:

Phone:

ex 650-555-1212 x1234
Fax#:
Primary Specialty/Subspecialty:   if Other:
Secondary Specialty/Subspecialty:
Are you interested in providing externship to: Medical Students     Residency Applicants  

Expected Duration:

Any special qualities you desire in prospective externship candidates:

Are you interested in helping our Residency applicants?

Yes    No

Which specialties:   if Other:
Which Hospital/Residency program:

Any special qualities you desire in prospective applicants: eg USLME Scores, Sex, Experience

Are you interested in helping our Fellowship applicants?

Yes    No

Which Subspecialties:
Which Hospital/Residency program:

Any special qualities you desire in prospective applicants:

   
 
   
   
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