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Electives
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Electives Form
Electives Application Form
Name:
Country of Birth:
(select country)
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
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Gabon
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Iran
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Kosovo
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Laos
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Lebanon
Lesotho
Liberia
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Liechtenstein
Lithuania
Luxembourg
Macau
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Mauritius
Mayotte
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Moldavia
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Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
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Niger
Nigeria
Niue
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Northern Mariana Islands
Norway
Oman
Pakistan
Palau
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Panama
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Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Re union
Republic of Dominica
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Samoa
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Saudi Arabia
Senegal
Serbia
Seychelles
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Slovenia
Solomon Islands
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Spain
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Swaziland
Sweden
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Thailand
Togo
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USA
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Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Home University:
Current Year of Academic Study:
Year 4
Year 5
Proposed Start Date:
Date and time
Calendar
Now
Proposed End Date:
Date and time
Calendar
Now
Duration (weeks):
Email Contact:
Telephone Contact:
Choose 3 Disciplines:
Accident & Emergency
Anaesthesiology
Child Health
Community Health
ENT
Family Medicine
General Medicine
General Surgery
Obstetrics & Gynaecology
Ophthalmology
Orthopaedics
Pathology
Psychiatry
Note:
Please select 3 disciplines only.
Questions/Comments: