Externship Request Form

Application for Externship in General Surgery |
Swedish Medical Center

Please complete this form in its entirety. If you have any questions about the form or about the externship program, please contact the Department of Surgical Education at (206)386.2123.

First Name:
Middle Name:
Last Name:

Present Address:
City:
State:
Zip/Postal Code:
Phone:

Home Address:
City:
State:
Zip/Postal Code:
Phone:

E-Mail:

Undergraduate University:
Degree / Year Received:
Medical School:
Degree / Year Expected:

Clinical Clerkships Completed (please list all consecutively)
Requested Externship Date Options (Maximum of 4 weeks only):

1st Choice:	through
2nd Choice:	through
Will your Dean's Office expect an evaluation of your performance?	Yes No
Malpractice Insurance (NOTE: Hospital policy requires coverage. Please forward verification to the address below):

Director of Surgical Education
Swedish Medical Center / First Hill
747 Broadway, 7th Floor West
Seattle, WA 98122-4307
206.386.2123

Surgical Education
March 2002


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