Clerkships Application

Thank you for your interest in a clerkship at the University of Wyoming Family Medicine Residency Program at Casper.

Please provide the following information to help us organize our program schedule. Although we ask for a first and second choice of dates, if there is only one date that you can come, fill in that blank only.

Thank you!

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Name:
Email:
Address:
City:
State:	Choose a State Wyoming Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Other
Zip:
Cell Phone:
School:
Graduation Year:

Dates you would like to come:
1st Choice:	to
2nd Choice:	to
USMLE and/or COMLEX Scores:
Area in medicine of primary interest to you:
Explain briefly your interest in the Casper program and Wyoming:
What is your interest in rural medicine and the underserved population, as that is our program’s main focus:
Please provide other information or questions you may have: