Application Form

Undergraduate Studies

3333 Green Bay Road
North Chicago, Illinois 60064-3095

Undergraduate Studies
Phone: 847 578 8603
Fax: 847 578 8778

CPR - 1

USMLE, STEP 1 REVIEW COURSE

APPLICATION

Please ENTER your information on this page, then PRINT it and MAIL a copy to us at:

Dr. Gordon Pullen, PhD
Department for Educational Affairs
Rosalind Franklin University of Medicine and Science
3333 Green Bay Road
North Chicago, IL 60064

NOTE: The information you enter on this form will NOT transfer to a web-based data file--you must use the U.S. mail.

Name:
Email address:
Social Security Number:
Date of Birth:
Preferred address (while at school):
Preferred phone number:
Your Medical School:
Dean of Your Medical School:
Permanent Address:
Alternate phone number:
Name and address of the person most likely to know how to contact you over the years:
Contact person phone number:
Release of Information:	I hereby authorize the administrators of the CPR For Boards review course of the Rosalind Franklin University of Medicine and Science to have access to my Medical School transcripts and other supporting documents (e.g., USMLE scores): 1. To facilitate review of my application to attend the course; 2. To assist in evaluation of my academic progress with the goal of discovering areas that might need special emphasis during the review course; 3. To evaluate the effectiveness of the CPR course in furthering my academic and career goals.
Signature:
Date:

Return to CPR 1 Course Description

Return to the list of requirements for application materials