Application Form
Letter of Eligibility or Long Term Clerkship Certificate

Please return form to:

 
Simone Keo
NYS State Board of Education
89 Washington Avenue
3rd Floor-West Wing
Albany, New York 12234
Phone: 518-474-3817, Ext. 560
Fax: 518-486-4846
Email: skeo@mail.nysed.gov
Please refer to the New York State 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: _____________________________________________________
_____________________________________________________
Telephone No.: ______________________ Date of Birth: _____________

I have enclosed the following:
Check for $30 (Letter of Eligibility)s
Check for $20 (Long Term Clerkship Certificate)
Original USMLE Score Report (Long Term Clerkship Only)

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. Please do not send cash through the mail.

I am applying for the following clinical clerkship at:
___________________________________________ ___________________________________________
(Name of Teaching Hospital)
(Name of Rotation)

Dates of Rotation: ___/___/______ to ___/___/______ for a total of ________ weeks.

 

I am currently enrolled in the following medical school.

_______________________________________________________________________
(Name of Medical School)

Statement:
I have / have not (please circle one) engaged in clinical clerkships in the State of New York since May 1, 1981." Specify below or on the back of the form any clerkships since May 1, 1981.


___________________________________________ ___/___/______
(Signature)
(Date)