WEILL CORNELL MEDICAL COLLEGE

OFFICE OF GLOBAL HEALTH EDUCATION

INTERNATIONAL ELECTIVE APPLICATION FORM
Complete and return application to: globalhealthelectives@med.cornell.edu

A: PERSONAL INFORMATION
To be completed by student. Please print or type
NAME AS IT APPEARS ON TRAVEL DOCUMENTS:
Last SHAH First PALAV Middle SHREYANS
Preferred Name PALAV SHAH Male [ ] Female [ ]
Date of Birth [MM/DD/YEAR] 11/19/1995
Citizenship INDIAN
Mailing Address
Street 344/1 , ISHWAR KRUPA SOCIETY
Apt # SECTOR-22, GH-5
City GANDHINAGAR
State GUJARAT Zip 382024
Country INDIA
Email address palavshah19@gmail.com
Telephone Number +91 8238927733
Name of Undergraduate School (if applicable):
Name of Medical School + Country Degree Awarded & Exp. Date of
GCS Medical College, Hospital and Research Centre Graduation
INDIA 5TH YEAR MBBS STUDENT
Exp. Date of graduation- JUNE 2019

School Contact
Name GCS MEDICAL COLLEGE , Email deangcsmc@gmail.com
HOSPITAL AND RESEARCH CENTRE
Emergency Contact
Name SHREYANS SHAH Telephone +91 9825297733

B: ELECTIVE CHOICES AND DATES

Use catalogue to find the elective codes ex. MEDC 8108. Only list each elective once with recommended 6-9 electives in order of
preference. The listed electives will be considered for the entirety of dates, based on availability.

Dates Elective Choices

1) 04/01/2019 - 1) PEDS 8127 10 NYP 2)MEDC 8104 10 NYP 3)MEDC 8112 10
04/28/2019 NYP
2) 02/25/2019 - 4) MEDC 8157 10 5) MEDC 8173 10 NYP 6)MEDC 8175 10
03/24/2019 NYP NYP
3) 04/29/2019 - 7)PEDS 8116 10 NYP 8) PEDS 8203 19 NYP 9)PEDS 8302 10 NYP
05/26/2019

I have read and understood the application materials. I attest that the information given in this
application is accurate and true.
Student’s Signature: _

____ __________________Date:__06/28/2018_______________________
Attach in PDF format:
 Non- refundable Application Fee $300 USD *ONLY PayPal and Personal Checks/Money Orders accepted*
 Curriculum Vitae (with photo)  Health Statement Form (1 page)
 Dean/Registrar Verification Form  Statement of Intent
 Dean’s Letter +++++++  Official Transcript with Grades/Marks
 Health Insurance Policy (after approval)  Malpractice Insurance Policy (after approval)