Be sure to consult with your school before faxing or
mailing this form to ensure that you receive credit for your selection and
avoid a last minute change or cancellation due to a conflict with your
school's schedule.
NAME
(LAST, First and Middle Initial):
Permanent
mailing address
(Street, City, State, ZIP):
Permanent
telephone number(s)
(###) - ### - ####:
Permanent
e-mail address:
Current
school name and location:
Academic
school year during training:
Training
category:
Trainee
type:
I will be
an active duty trainee:
YESNO
Primary Rotation and
Alternate Choices: You must
fill out the Primary Rotation section. If the Alternate Primary Rotation is
left blank, then you will only be considered for your primary choice. If
this is not available, you will be notified by mail.
IMPORTANT NOTE: Your begin date must be a Monday and the end date a
Friday. Any exceptions to this rule must have an explanation under the
"Comments" section for consideration.
Primary Rotation:
Primary Begin Day:
Primary Begin Month:
Primary Begin Year
(i.e., 2004):
Primary End Day:
Primary End Month:
Primary End Year (i.e.,
2004):
OR
Primary Begin Day:
Primary Begin Month:
Primary Begin Year
(i.e., 2004):
Primary End Day:
Primary End Month:
Primary End Year (i.e.,
2004):
Alternate Primary Rotation:
Alt Primary Begin Day:
Alt Primary Begin Month:
Alt Primary Begin Year
(i.e., 2004):
Alt Primary End Day:
Alt Primary End Month:
Alt Primary End Year
(i.e., 2004):
OR
Alt Primary Begin Day:
Alt Primary Begin Month:
Alt Primary Begin Year
(i.e., 2004):
Alt Primary End Day:
Alt Primary End Month:
Alt Primary End Year
(i.e., 2004):
Second Rotation and
Alternate Choices:
If you only wish to do one rotation at TAMC, it is not necessary to fill in
the blocks for a second and alternate second rotation.
Second Rotation:
Second Begin Day:
Second Begin Month:
Second Begin Year (i.e.,
2004):
Second End Day:
Second End Month:
Second End Year (i.e.,
2004):
OR
Second Begin Day:
Second Begin Month:
Second Begin Year (i.e.,
2004):
Second End Day:
Second End Month:
Second End Year (i.e.,
2004):
Alternate Second Rotation:
Alt Second Begin Day:
Alt Second Begin Month:
Alt Second Begin Year
(i.e., 2004):
Alt Second End Day:
Alt Second End Month:
Alt Second End Year
(i.e., 2004):
OR
Alt Second Begin Day:
Alt Second Begin Month:
Alt Second Begin Year
(i.e., 2004):
Alt Second End Day:
Alt Second End Month:
Alt Second End Year
(i.e., 2004):
Enter your comments below
(or provide any additional information that may be helpful in scheduling a
rotation for you.) Examples: Are you interested in residency at TAMC? Do
you plan on interviewing with our program director? Tell us if you have any
special requirements for your training? If you are applying for a third-year
rotation and select a specialty rotation, let us know if you have satisfied
your core requirements. If you provide us with your individual educational
needs, it will help us assist you with scheduling at our medical center more
efficiently and effectively.
Enter your comments here:
TO AVOID A DELAY IN
THE PROCESSING OF YOUR APPLICATION, SIGNATURE, SSN AND DATE IS NECESSARY.
Signature of Requestor/Student
Social Security Number
Today's Date
Sign this
completed form, provide SSN, and date before faxing to:
TAMC Medical
Clerkship Coordinator @ (808) 433–1559.
OR
Print this completed
form, sign and date it. Then mail the form to:
Tripler Army Medical Center
Medical
Clerkship Coordinator
ATTN: MCHK-HE-ME (9th floor, A-wing, Room 9A008A)
1 Jarrett White Road
Tripler AMC, HI 96859-5000