Punjab Institute of Cardiology (PIC)

Department of Research and CME, Lahore, Pakistan

Application for Medical Student Elective Rotation

Please print or type

Please list alternate choice that you would be interested in doing if your first choice were
already filled.
Research
Elective
Clinical Elective
Observer ship
1st Choice (Department/Date)_____________________________________________________
2nd Choice (Department/Date)____________________________________________________
Personal Data
Name in full (please do not use initials)______________________________________________
Present mailing address (Street/City/Province/Zip)________________________________________
_____________________________________________________________________________
Permanent address (Street/City/Province/Zip)____________________________________________
_____________________________________________________________________________
Home Telephone (Area Code)/E-Mail Address ________________________________________
Email_________________________________________________________________________
Pakistan Citizen _____ YES ____ NO

National ID Card Number____________________________

Education
Name and location of school - include date of attendance and degree obtained (if graduated).
Pre-medical____________________________________________________________________
Medical ________________________________ Graduation Date (mm/dd/yy)_______________

Year of Study at the time of Electives________ Expected Year of Graduation______________

TO BE COMPLETED BY YOUR DEAN'S OFFICE
Please ask your Dean or Faculty to send a general letter of recommendation, stating that you are
a student in good standing and may do an extramural elective. Please attach your recent Transcript.
1. The medical student named above is in good standing and is in the_____ year of
___________________program. He/she is authorized to take this elective.

2. The student (will) (will not) have completed junior level rotations in Internal Medicine, Surgery,
_______________________________________________________________________
Pediatrics and Cardiology before taking the above requested elective(s).
_______________________________________________________________________
______________________________________ Signature/title of school official
_______________________________________________________________________
______________________________________ Print school official's name
Have you attended any BCLS, ACLS, ATLS Course?
______________________________________
School /Seal
_______________________________________________________________________
School
name/mailing
address
PIC is not
responsible for
providing accommodations.
We might facilitate some arrangement but it is highly recommended that student arrange for themselves.

_______________________________________________________________________
Need housing
Yes __ No__
_______________________________________________________________________
I certify that the information given on attached is true, accurate and complete.
Telephone/Area Code_____________________________________________________
Signature _________________________________________________
Hospital Experience--Please note clinical clerkships and electives completed prior to
Date
_______________________________
date of
rotation requested at your Institute of Study:
_______________________________________________________________________
PIC reserves the right to accept or reject an application
All applicants will be notified about their application status
_______________________________________________________________________
Within 15 days of receipt of application by email
Department of Research and Continued Medical Education
_______________________________________________________________________

2nd Floor Conference Room

Punjab
Cardiology,
Lahore,
Pakistan
Insurance Issues--PIC will not
coverInstitute
for any of
Insurance.
Students
must
arrange one for themselves.
92 42 9203051-65 Extension 271, 92 42 9203206
Fax: 91 42 9203207

Health Issues--Are you aware of any limitations that would prevent and/or limit you from
Performing the duties of the medical student rotation for which you are applying?
_______________________
Immunization Requirements - Students must provide proof of immunizations (see policies)
Tuberculin Testing:
What was the date of your last tuberculin test? ________________
What were the results? ___ Positive ___ Negative
If your test was positive, you are expected to begin treatment prior to your arrival at PIC.

Hepatitis B: Have you had the Hepatitis B vaccination?

___Yes ___ No
Meningitis: Have you had meningitis vaccination

___Yes

___No

Additional Information--Give full name and mailing address of individual at your school who is
to receive your evaluation and grade, if due.