ILMA advisory form

Full Name *

Medical School *

I am currently a: *

I graduated/will graduate in (provide the year): *

Field of interest (i.e., internal medicine, surgery…) *

I am interested in getting help with (select all that apply): *

If applying to residency, provide the anticipated year of applying to the Match *

If applying for an elective or fellowship, provide the anticipated month/year and the desired specialty *

STEP exams completed

Provide us with your email *

Provide us with your phone number (optional)

Would you like to be contacted by ILMA members for further assistance *

Are you ECFMG certified? *

Are you a US citizen or greencard holder? (This is usually helpful for electives, research opportunities…): *

Previous research experience if applicable :

Number of publications if applicable :

Previous electives/observerships in the US. If yes, the name of the program and specialty: