Central Maine Medical Center Family Medicine Residency Program

CENTRAL MAINE MEDICAL CENTER Family Medicine Residency

APPLICATION: Medical Student Rotation

NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP:
E-MAIL:
TELEPHONE: HOME #
TELEPHONE: Cell #

NAME OF SCHOOL:
CONTACT NAME (Clinical Rotation Coordinator):
CONTACT E-MAIL ADDRESS:
CONTACT PHONE NUMBER:
SCHOOL ADDRESS:
YEAR OF GRADUATION:
HONORS/ACTIVITIES:

DATES OF ROTATION:
First Choice
Second Choice
Third Choice

ROTATION REQUESTED:
First Choice
Second Choice
Third Choice

Are you interested in all of the choices, if they are available based on the dates you provided?
YES NO

Are you interested in other rotations that are not listed, if so, what are they?

What are your future career goals (specialty, type of practice, and/or other professional goals)?

Are you planning to interview with the FM Residency while you are here? (This is for planning purposes only).
YES NO

What are your ties to Maine or the Northeast?

How did you hear about our program? (Please let us know if you have specifically spoken to our faculty/residents/students and in what venue this happened).

FOR THOSE WHO HAVE GRADUATED MEDICAL SCHOOL - Please provide a list of all the core and clerkship rotations you completed while in medical school.

WHAT TYPE OF RESIDENCY TRAINING ARE YOU PLANNING TO PURSUE AFTER MEDICAL SCHOOL? (List if known)

HOUSING: Will you need full time housing?
YES NO

If completing a rotation requiring call, and you are commuting, a call room will be provided.
WE RECOMMEND THAT YOU HAVE YOUR OWN TRANSPORTATION, AS PART OF YOUR ROTATION MAY BE LOCATED OFF CMMC CAMPUS AS WELL AS FOR SIGHT-SEEING PURPOSES.

FURTHER INFORMATION REGARDING HOUSING, MEALS, SCHEDULING, ETC. WILL FOLLOW WHEN THE ROTATION(S) YOU HAVE REQUESTED HAVE BEEN CONFIRMED.

If you have graduated medical school, in addition to submitting this application, please e-mail your CV to Jill Freda fredaji@cmhc.org

YOUR APPLICATION WILL BE CONSIDERED IN THE ORDER THAT IT IS RECEIVED.

CONTACT
PERSON(S):

Jill Freda, M.S., or
Deborah Taylor, Ph.D.
CMMC FM Residency Program
76 High Street
Lewiston, ME
(207) 795-2824
{During the hours of 8:00am - 4:00pm}
fax (207)795-2190
E-mail address: fredaji@cmhc.org

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