Application Form Letter Of Eligibility Or Long Term Clerkship Certificate - Nysed-State Board For Medicine
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1APPLICATION FORM
LETTER OF ELIGIBILITY OR LONG TERM CLERKSHIP CERTIFICATE
Please return form to:
NYSED-State Board for Medicine
Phone: 518-474-3817, Ext. 560
89 Washington Avenue
Fax: 518-486-4846
nd
West Wing-2
Floor
E-Mail: clinicalclerkship@mail.nysed.gov
Albany, New York 12234
Please refer to the enclosed 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)
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 confirmed for the following clinical clerkship at the hospital named below:
________________________________
_________________________________________
(Name of Rotation)
(Name of Teaching Hospital)
Dates of Rotation____/____/____ to ____/____/____ for a total of _________ weeks.
I am currently enrolled in the following medical school.
(Name of Medical School)
Statement:
Please check one “ I have /have not 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)
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