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Application for the Clinical Medicine Program (CMP)
NOTE: Do not press the "Back" button at any time while completing this application, as your information will be lost.
General Information
Name of GMC Clinical Advisor Social Security / Social Insurance Number
First name Middle initial
Last name
Address 1 Address 2
Address 3
City State
Zip Province
Country
Email Address Phone number (include Area Code)
U.S. Immigration statUS
U.S. Citizen U.S. Permanent Resident
Canadian Citizen
U.S. Visa Type / Length Other (please specify)
Program applying to
Clinical Medicine Program - Comprehensive (# of Weeks:)
Clinical Medicine Program - Select (# of Weeks:)
Rotation Specialty Applying to
(OB/GYN is currently unavailable for Graduates; 12 weeks minimum for Surgery on a limited basis)
CORE SPECIALTIES
Family Practice Psychiatry
Pediatrics General Surgery
Internal Medicine
ELECTIVE SPECIALTIES
Infectious Disease Nephrology
Hematology & Oncology Immunology & Allergy
Gastroenterology Neurology
Cardiology Pulmonology
Peer Review Research Sleep Medicine
Dermatology Ophthalmology
Catastrophic Medicine & Long Term Care Urology
Neurosurgery ColorectalSurgery
CMP LOCATION
Atlanta, Georgia
Other (please specify)
Approximate Start Date Requested
Medical Education
ECFMG Certified? Yes No Year of Medical School Graduation: (mo/yr) /
Passed USMLE 1? Yes No If Yes: (mo/yr) /
3 Digit Score
Passed USMLE 2CK? Yes No If Yes: (mo/yr) /
3 Digit Score
Passed USMLE 3? Yes No If Yes: (mo/yr) /
3 Digit Score
Passed USMLE 2CS? Yes No If Yes: (mo/yr) /
3 Digit Score
Medical School Graduated From
City State
Zip Province
Country
Final Degree(s) issued
Recent (below 12 mo) US Letters of Recommendation? Yes No If Yes: How many?
US Hands on Clinical Experience? Yes No If Yes
Location
Location
Location
Financial Information
How do you plan to finance your CMP tuition? Cash/Check/Cashiers Check
Personal Financing
Family Financing
Credit Card (American Express, Diners Club, Discover, JCB, MasterCard, Eurocard, Visa, Visa Check Cards)
Direct Wire Transfer
Other: please specify
Signature
All data collected on this Application Form is private and confidential. The information collected on will only be used internally, and will not be released to persons or institutions outside of GMC and its partners witout your consent. Some states have statutes that require background checks on persons who provide care for others or have access to people who receive care. This law applies to all persons who are employed in the care-giving industry or have formal access to individuals being served by the care-giving industry. As part of your course studies you will be placed in a clinical site(s), and therefore you will be subject to a background check. By signing below you agree that we may conduct and use consumer credit and background check reports. You further certify that you have not been convicted of, nor have charges pending against you for a serioUS crime. Note: A background check will only be done should you be accepted into the program.
Name of Applicant Date
Please only submit once. Submitting multiple applications could delay processing.
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Copyright 2000-2007. A Member of The Greater Medical Center of Medical Professionals-USA. This document is provided for information purposes;
the content and structure of the Clinical Medicine Program may be changed at the discretion of GMC without prior notice.


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