American Medical International Quality Training

Clinical Rotations for International Medical Students

2112 F Street NW, Suite 303 Washington, DC 20037
202.728.0099 Ext. 103 | info@[Link]

Registration/Application Form
Applicant Information
Full Name: Date:
Last First M.I.

Address:
Street Address Apartment/Unit #

City State ZIP Code

Phone: Email

Emergency Contact: Phone: Email:

Country of Citizenship: Type of Visa: Expiration Date:

I-94 #:

Rotation Information

What Rotations would you like to do? When? (month & year) Hands-on or Observership
1.

2.

3.

4.

5.

Education

Medical University:

Address:
Street Address

City State ZIP Code Country

YES NO
From: To: Did you graduate? Diploma:

Admissions Counselor: _________________________ Ph: _________________Email: _______________________

1 From updated 10/2024

 Languages

What Languages do you know? Speaking* Writing*

[Link]
2.
3.
4.
*Levels for speaking and writing: Basic, Intermediate, Fluent, or Native.

Required Documents
For AMIQT use only

1
1) Personal Statement / Essay (in less than 300 words please indicate why you
would like to do this rotation and state your goals in medicine) 2
2) If you are a GRADUATE, please explain how you have been spending
your time since graduation.
3
3) CV (Curriculum Vitae) / Resume 4
4) Letter of Good Standing from University 5
5) Government Issued Photo ID 6
6) Criminal Background Check 7
7) Medical Malpractice Insurance (for Hands-on experience) (for certain rotations) 8
8) Current Physical Exam 9
9) Immunizations records / Antibody Titers 10
1 MMR (Measles, Mumps, Rubella) 11
2 TDaP (Tetanus, Diphtheria, Pertussis) 11-1
3 Varicella 11-2
4 Hepatitis B 11-3
5 Tuberculosis Testing (PPD - or Clear Chest X-ray)
11-4
6 Flu Shot (applicable only during flu season)
11-5
11-6

AMIQT offers housing with fully furnished units. All utilities (water,
electricity, gas, internet, trash removal) are included. Yes No
Price: $330-360/week, $150 cleaning fee. Would you like more
information?

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
I understand that false or misleading information in my application or interview may result in termination of the rotation.
I Understand that Application fee is non-refundable. Tuition fee is fully refundable if cancelled 1-month prior, partial refund if
cancelled 2-week prior, non-refundable if cancelled 1-week prior.

Signature: Date:

2 From updated 10/2024