BROOKLYN USCE OLD GRADUATE PACKAGE (DEPOSIT FORM)

BROOKLYN USCE OLD GRADUATE PACKAGE FORM

DEPOSIT FEE
Name (As on Passport)*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Country/ Postal / Zip Code
WhatsApp Number Country Code *
eg 1 (USA) or 91 (India)
WhatsApp Phone Number*
Please enter a 10 digit valid phone number.
Name of Medical school (Include city, state and Country) :*
General Medicine 1 (On-site)General Medicine 2 (On-site)General Medicine 3 (On-site)General Medicine 4 (On-site)General IM Michigan (On-site)Family Medicine FM1 (On-site)Family Medicine FM2 (On-site)Family Medicine FM3 (On-site)Hematology-Oncology (On-site)Cardiology C1 (On-site)Cardiology C2 (On-site)Cardiology C3 (On-site)Cardiology C4 (On-site)Gastroenterology GI1 (On-site)Gastroenterology GI2 (On-site)Nephrology N1 (On-site)Nephrology N2 (On-site)Radiology (On-site)Pathology P1 (On-site)Pathology P2 (On-site)Neurology (On-site)Psychiatry (On-site)Pediatrics PE1 (On-site)Pediatrics PE2 (On-site)Pediatrics PE3 (On-site)Pediatrics PE4 (On-site)Rheumatology RH1 (On-site)Rheumatology RH2 (On-site)Endocrinology (On-site)Dermatology (On-site)Plastic surgery (On-site)Neurosurgery (On-site)Other
Preferred Start Date: *

MonthDayYear
Please select Monday of the week
Email all documents mentioned below at Electives@BrooklynUSCE.com

We will require the following documents:

1. Valid passport and *USA visa.
2. Proof of medical school enrollment/graduation certificate.
3. Recent photo.
4. *Recent immunization records (PPD test within 12 months, MMR, TDaP, Hep B titers, or proof of vaccination. Influenza shot proof. )
5. USMLE exam score report (if any)
6. *Valid Health Insurance
7. HIPAA Certificate (https://www.hipaatraining.com/)
8. Infection Control Certificate (https://bit.ly/3nfXrsC)

*Please note: USA VISA, Immunization records, and valid health insurance is not required for telemedicine rotation.

All documents have to be emailed at least 2 weeks before the rotation start date. Failure to submit the documents will lead to the automatic cancellation of your rotation.

Rotation plan *

16 weeks Old Graduate rotation deposit fee

Standard package can be postponed with a charge, but is not refundable and non-transferable. Please check terms and conditions for more information. The remaining balance of $4500 to be paid at least 2 weeks before the rotation start date.

$2,000.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

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BROOKLYN USCE OLD GRADUATE PACKAGE FORM

Credit Card/Debit Card