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Application Form Letter Of Eligibility Or Long-Term Clerkship Certificate - New York State Education Dept. Page 2

APPLICATION FORM

LETTER OF ELIGIBILITY OR LONG-TERM CLERKSHIP CERTIFICATE

Please return to:

New York State Education Dept.

State Board for Medicine

89 Washington Avenue, 3rd Floor West

Albany, New York 12234

Email: ClinicalClerkship@mail.nysed.gov

Attn: Mary Pressley Smith Tel. 518-474-3817 ext. 560

TO AVOID DELAYS IN PROCESSING, PLEASE PRINT LEGIBLY

Please refer to the enclosed New York Sate Education Department regulations before completing this application form

I am applying for :

__ Letter of Eligibility (12 weeks or less)

__ Long-Term Clerkship (More than 12 weeks)

Name:

____________________________________________

Address: _________________________________City and State_________________________________

Tel Nos. ________________________________

Cell: _____________________________________

Date of Birth:

month) (day) (year

EMAIL ADDRESS: ________________________________________________________________________________

I have enclosed the following: __ check for $30 (Letter of Eligibility)

__ check for $20 (Long-Term Clerkship)

__ Letter of good standing from medical school attended

__ Letter of acceptance from hospital where clinical rotation will be done

__ original USMLE Score Report

(must be included for students attending approved schools for all rotations)

___ Completed REQUIRED NYS Infection Control course

Note: Check or money order must be drawn on a U.S. bank in U.S. dollars and payable to the New York State Education

Department. Traveler’s checks are not accepted for payment. Please do not send cash through the mail.

I am confirmed for the following clinical clerkship at the hospital named below:

_________________________________________

__________________________________________________

(Name of Rotation)

(Name of Hospital)

Dates of Rotation: ____/ ____/ ____/ to ____/____/____ for a total of _____ weeks.

mo. day year

I am currently enrolled in the following medical school: ___________________________________________________________

Statement: I have / have not (circle one) engaged in clinical clerkships in the State of new York Since May 1, 1981.

Specify below any New York State clerkships since May 1, 1981.

__________________________________________

____/ ____/ ____

Signature

mo. day year

Revised 01/24/13

Application Form Letter Of Eligibility Or Long-Term Clerkship Certificate - New York State Education Dept. Page 2

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