Pursuant to New York State Department of Health 405.4, any International Medical Graduate (IMG) enrolled in a medical school after 10/1/83 must have completed his clerkship, including “no more than 12 weeks of clinical clerkship in a country other than the country in which the medical school is located.” Any IMG who completed more than 12 weeks of clinical clerkship outside of their medical school’s home country is NOT eligible for graduate medical training in New York State; exceptions may be made only if approved by the New York State Education Department (please note the approved schools listed below).

Kindly answer the following questions:

1) Did you attend one of the following NY State approved medical schools? YES (Please check your school and sign #4 below) NO (Please continue to #2)

• American University of Antigua, Antigua (June 2006)

• American University of the Caribbean, Cupecoy, St. Martin (March 2003) • The Autonomous University of Guadalajara, Guadalajara, Mexico (March 2000) • English Language Program, University of Debrecen, Medical and Health Science Center, Medical School, Debrecen, Hungary (December 2005) • English Language Program, Medical University of Lublin, Lublin, Poland (September 1999) • English Language Program, Medical University of Silesia, Katowice, Poland (June 2000) • Fatima College of Medicine, Manila, Philippines (June 1988) • International Health and Medicine Program, Ben Gurion University of the Negrev, Beer-Sheva, Israel (February 2002) • Kasturba Medical College, Manipal, India (April 2005) • Medical University of the Americas/Nevis, Nevis, West Indies (March 2006) • Ross University School of Medicine, Roseau, Dominica (October 1999) • Saba University School of Medicine, The Bottom, Saba (August 2005) • St. George's University School of Medicine, St. George's, Grenada (January 1987) • St. Matthew's University School of Medicine, Grand Cayman, Cayman Islands (April 2004) • Technion Israel Institute of Technology - Technion American Medical Students Program (TEAMS), Haifa, Israel (July 2014)

• The University of Queensland, Brisbane, Australia (March 2017) • Xavier University School of Medicine, Oranjestad, Aruba (July 2020)

2) Have or will you complete MORE THAN 12 weeks of clinical clerkship in a country other than the country in which your medical school is located? YES (Please continue to #2b) NO (Please continue to #3)

2b) Was your clinical clerkship(s) prior to 10/1/83? YES (if ‘YES’, then go to #4) NO (if ‘NO’, you are not eligible for training in NYS)

3) Please fill out and submit documentation of clinical clerkship(s) completed and go to #4: Type of Clerkships Location (Name of Hospital) Date (month/day/year) # of weeks (i.e., IM, Surgery, OB) (City, State & Country) {beginning – ending}

4) By signing this document, I hereby attest that I understand the New York State regulation regarding residency training for International Medical Graduates and that I am eligible for training.

Name (print) Signature Date