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Student Clerkship Application Form
Name
*
First
Last
Medical School
*
Are you looking for Rotations in the USA or Canada?
*
USA
CANADA
BOTH
Email
*
Confirm Email
*
Year
*
3rd year
4th year
post grad
Have your passed any licensing Exams? Please check all that apply
*
USMLE Step 1
USMLE Step 2 CK
USMLE Step 2 CS
USMLE Step 3
MCCEE
MCCQE 1
MCCQE 2
Have you ever failed any licensing examinations?
*
Yes
No
If you answered YES, which exam(s) did you fail and how many attempts were made
*
What are you interested in pursuing?
*
Core Rotation
Elective Rotation
Research
How did you hear about us?
*
Another student using HCG
Friend
My School
Internet Search (Google)
Value MD
Poster/Flyer
Please check off all of the clerkships you would like to complete through HCG
*
Internal Medicine
Surgery
Psychiatry
Family Medicine
Pediatrics
OB/GYN
Other: (please specify)
*
.
.
*
Cardiology
Nephrology
Emergency Medicine
Hem/Oncology
Gastroenterology
.
.
*
Infectious Disease
Neonatology
Additional Questions, Comments or Concerns
*
*
Heartland Clerkships takes all applications seriously
. Please do not lie or submit misleading information. If we find out that information was falsified now or at/during any stage of the clerkship process, we will revoke your clerkship and withhold any refunds.
By clicking Submit, you agree to these terms and conditions.
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