Application for Visiting Externship in Medicine Please type or print legibly. Deadline for applying is April 30, 2016. Rotation Request Rotation requested for: (June, July, or August) Personal Information Name (Last, First, Middle) Gender Mailing Address (Street) Telephone/Cell Number (City, State, Zip Code) E-Mail Address Social Security Number Age Date of Birth (Month/Day/Year) I self-identify as (Race/Ethnicity) Place of Birth USMLE Step 1 Score (Please attach copy of score report) Medical College (Name, City, State, Country) Expected Graduation Date Personal Statement: Please tell us why you are interested in this opportunity at Jefferson In signing this application the physician submitting hereby certifies that the information given is true. Rotations are contingent upon requirements of the Pennsylvania State Board of Medicine and the Thomas Jefferson University Hospital Graduate Medical Education Committee. Signature of Applicant Date