Applying Problems?

Please copy and paste this into an email and send it to romp@romponline.com.

1) Last Name, First Name

2) Date of Birth

3) Telephone Number & email address

4) Use of car

5) Home Address (including postal code)

6) Intended year of graduation

7) Medical School attended

8) Student Number

9) What year you will be in during the rotation

10) Rotation Dates

11) 3 Community Choices

12) Core or Elective rotation

13) Do you already have a preceptor? If so what is the preceptor's name.

14) Discipline

15) Expectations of Learning-any extra info you think ROMP will need to set up your rotation

16) For Residents only

Current University

CMPA# -

CPSO# -

Year of Residency Completion -