APPLICATION FORM
To apply for the International Post Graduate Observership Course please print, complete and mail the application form with your registration fee, and include all the required documents listed below.

Last name __________________________ First name ______________________
Address _________________________________________________________
City ___________________________State/Country ______________________
Zip Code ___________ Telephone ____________________________________
E-mail ______________________________ Fax ________________________
Citizenship _____________________________
Visa Status _____________________________ 

I WISH TO ATTEND COURSE
a) ____________________________________ No. ______________

OR

b) ____________________________________ No. ______________

DATE REQUESTED:
1st Choice ________________________________ (Month)

2nd Choice ________________________________ (Month)

Have you ever attended a Post Graduate Observership Course or Mini-Residency at Mount Sinai Medical Center      YES       NO

If yes, when – date(s)  ___________________________________________ 
 
What Course(s) _________________________________________________

Please include with this form the following documents and send to the address below: 

• Copy of Medical School Diploma (Include translation in English if is in a foreign language)
• Curriculum Vita or Resume (Include supporting documents)
• Registration fee $750.00 per course (Include check, money order or credit card)
• Copy of USMLE - Minimum scores of 80 required on all Steps.
• Personal statement regarding your experience in the chosen field
• Current PPD documentation

  METHOD OF PAYMENT
  A) Check payable to Mount Sinai Medical Center
  B) Credit Card:  ___ Visa  ___ Master Card  ___ American Express 
  C) Money order payable to Mount Sinai Medical Center

Cardholders Name____________________________________________
(Name on credit card must be applicant's name.)
Card Number ________________________________________________
Expiration Date ______________________________________________
Cardholders Signature ________________________________________

Date of Application ___________________________________________

PLEASE SEND APPLICATION PACKAGE TO THE FOLLOWING ADDRESS:

International Observership Course
Attn: CME Coordinator
Department of Medical Education
Mount Sinai Medical Center
4300 Alton Road, Suite #2065
Miami Beach, FL 33140

For additional information please email CME_Coordinator@msmc.com

Please note:
*No course fees will be refunded for cancellations.
*A Non-US citizen wishing to participate in the International Post Graduate Observership Course shall be responsible for obtaining a B-1 or B-2 visa.  Mount Sinai Medical Center will not sponsor or support any visa.  Participants are not eligible for participation in our program with an F-1 student visa.
*Proof of citizenship and visa status will be requested upon arrival.