Affinity Medical Center - Externship Application

Affinity Medical Center
Medical Education Department
875 8th Street N.E.
Massillon, Ohio 44646

EXTERNSHIP APPLICATION

Name
College		Class of

Present Address		Permanent Address




Phone		Phone

E-mail address
Cell Phone

Preferred choice of contact:

Home phone

cell phone

e-mail

Please send correspondence to my

Present address

Permanent address

ROTATION REQUESTED
Discipline	From // to //
Preferred Physician (if applicable)
If my requested rotation is not available during the dates I have given, please attempt to schedule me for the following alternative rotation.
Discipline	From // to //
Preferred Physician (if applicable)

Discipline	From // to //
Preferred Physician (if applicable)

Do you have health insurance?	Do you have malpractice insurance?	Do you need housing?
yes no	yes no	yes no

Please forward a copy of your insurance coverage (health and malpractice) to Debbie Angle, Medical Education Department, OU-COM CORE Office, 875 8th Street N.E., Massillon, Ohio 44646