AUC

Elective Request Form
One Request Per Hospital
  *Required  
 

Student Information

  
  *Full Name:
  *Student ID#
  Email:
    
  Phone Number:
 

Hospital Information:
  Contact Person:
    
  Email:
    
  Hospital Name:
  Mailing Address:
  City:
 State
 Zip Code:
   
  1. Rotation Name:
      
  Start Date:          End Date:      
   
  2. Rotation Name:
      
  Start Date:          End Date:      
   
  3. Rotation Name:
      
  Start Date:          End Date:      
   
  4. Rotation Name:
      
  Start Date:          End Date:      
   
  Comments:
   
  Attach Document Here
  Document file name cannot have any spaces and only one document can be uploaded at a time. For example, a single document ready for upload should read like this: hospitalapplication.doc. or hospitalapplication.pdf. For elective requests with multiple documents please attach and send to clinicals@aucmed.edu.
   
  For non-affiliated sites, please use the pdf version of the elective request form to mail in your photo and application fee.
 
  The rotations on this form are requested only. This form does not confirm any of these elective rotations. Your student summary sheet can be updated only after OCSA receives a written confirmation from the hospital. Scheduling elective rotations without using the elective request form is strictly prohibited and could cause problems with students’ financial aid and licensure.