Your Full Name (First/Last, Given/Surname)

Your Email Address

Address -- No. & Street, City, State/Province, Country, Postal Code

Your City, State & Country

Telephone (include country code)

Your Citizenship

Name of University/Medical School

Address of University/Medical School

Medical School Start Date in (DD-MM-YYYY) Format:

Medical Graduation or Projected Graduation Date in (DD-MM-YYYY) Format:

Are you ECFMG certified?
YesNot YetNo, Not Planing To Certify

When are you planning to submit your application for the USMLE match in (DD-MM-YYYY) Format:

Have you applied to match in previous years?
YesWill be applying for the first timeNo, Not Planing To Apply

You are interested in?
Standard, hands-on, on-site rotationTelemedicine

Select ON-SITE, HANDS-ON REQUESTS, please indicate which specialty (on-site ONLY)
NonePaediatricsInternal MedicineNeurologyFamily MedicinePsychiatryObstetrics/GynecologySurgeryEmergencyRadiologyOther
If Other

Select TeleRotations REQUESTS, please indicate which specialty (TeleRotations ONLY)
NonePaediatricsInternal MedicineNeurologyFamily MedicinePsychiatryObstetrics/GynecologySurgeryEmergencyRadiologyOther

If Other

When would you like to begin your rotations?(choose any Monday) in (DD-MM-YYYY) Format:

Select what You Are requesting For:
One 4-week rotationTwo 4-week rotationsThree 4-week rotationsOther

Please add any additional information here about your request:

How did you hear about TeleRotations / R&T IMG Village?
A FriendSearch Engine, Like GoogleSocial MediaSocial Media AdsUSMLE-forumsother

Upload Your Resume Here

Upload a scan of the passport page that has your photo on it (or state ID for US residents).

Upload Medical school diploma or transcripts (graduates) or letter of good standing (current students).

Your message (optional)

By checking on this form you accept that the details provided in this form are 100% true.