Registration Form for Resident Rotating to UIMCC
University of Illinois Medical Center at Chicago
Resident Information:
Name of Resident ______________________________________________________________________
Social Security Number_________-______-____________
Dates of Rotation at UIC      From: ____________________    To: ____________________
Medical School (full name) __________________________________   City, Country __________________    
                                                          
Medical School (City and Country) _________________________________________________________
Date of Graduation from Medical School (Month Day, Year) _________________________
Phone/Pager Number: ____________________ Email Address: ____________________________
Current Training Program Information:
Current Training Program ________________________________________________________________
Current Institution and  Location ___________________________________________________________
Name of Current Program  Director ________________________________________________________
What was the first residency you began in the US? _____________________________________________
Start Date ____________________          End Date ____________________
What was the second residency you began in the US? ___________________________________________
Start Date ____________________          End Date ____________________
Visiting Training Program Information:
UIC Sponsoring Department/Division Where  Rotating ___________________________________________
New Innovations Rotation Name _____________________________________________
Print Name of Sponsoring Program Director/Faculty  Member _____________________________________
Signature of Sponsoring Program Director/Faculty Member Approval*_______________________________
                   Date ______________________________
                                                                                              
*All rotators must have the approval of either the Program Director or a supervising faculty member in the
UIC department where they will be rotating, in order to start the application process.
Graduates of Foreign Medical Schools must provide a copy of a Valid Indefinitely ECFMG certificate. ALL ROTATORS MUST complete this form as well as have UIC Director approval, GME Application, provide a copy of a current, valid Medical License, State ID/Passport and a Letter from current Program Director from his or her Institution.

Address questions to the GME Office:  312-996-2933.                                                                                                              09-25-07 sb