Mercy Health Partners Academic Affairs Application For Observership Name______________________________________________ Address ____________________________________________ City: ___________________________ State: _____________

Zip: ______________ Home Phone:________________ Cell Phone: _________________ Email address:_________________________ Best contact method: ________________

Medical school: _____________________________ Date graduated: ___________ USMLE Step 1 score: ____________ USMLE Step 1 attempts _________ USMLE Step 2 CK score __________ USMLE Step 2 CK attempts_______ USMLE Step 2 CS: Passed:_________ USMLE Step 2 CS attempts ______ ECFMG certification: No _____ United States Citizen ? Permanent Resident ? Yes___ Yes ___ Yes________ Date ____________ No ___ No ___

Are you currently eligible for employment in the United States ? Yes ___ No ___ Observerships are two weeks duration, starting on a Monday and ending on Sunday. Preferred dates for observership : ___/___/_____ to ___/___/_____

Rotation interest in ________________________________________________ Signature: __________________________________ Date: ___/___/_____

By signing this document, I certify that all information is accurate. I understand that any misrepresentation or falsification of information on this application will result in denial of or immediate suspension of any educational activities offered by Mercy Health Partners(MHP)Academic Affairs Department. I understand that there will be no academic credit that will be given to me for the observership completed at MHP; no certificates or letters will be issued . MHP can verify if called and or formally asked if I completed a strict "observership". I will have no patient care experience, only observation of patient care when granted permission to observe by the patient.

Fax completed application to: Academic Affairs 419-251-6795