i STATE UNIVERSITY OF NEW YORK HEALTH SCIENCE CENTER AT BROOKLYN | OFFICE OF THE REGISTRAR Basic SENCE BULDING L112. BOx98 ] REQUEST FOR CLERKSHIP CHANGE | (COLLEGE OF MEDICINE. INSTRUCTIONS: This Clerkship Change form must be completed if you desire to take a clerkship during any time other than what is. scheduled in your track. Note: Ifyou change clerkships, you may encounter limitations in hospital site choices. This form must be Submitted to the Office of the Registrar, Basic Scence Building Rem. 1-112 atleast 4 weeks prior tothe stat ofthe proposed change. Any form submitted less than two weeks prior to the start of the clerkship will be charged a $15 late fee. No change is considered offical ‘until appropriate required approvals appear on this form, and ithas been submitted to the Registrar's Ofice with any required fee paid. NOTE: Clerkships must be rescheduled, not dropped. ‘To Be EMLLED Our By STupENT ] NAME: De ADDRESS: Box # | | ET | ‘TELEPHONE: ar TATE IF PROPOSED CHANGE: Curekstar: ‘CURRENT DATES: ‘DesiRED DATES: | Daron ‘SuBMIT TO THE OFFICE OF THE REGISTRAR IF THE DATE OF THIS Sumarr70 Te CurRstit? DIRECTOR IF THE DATE OF THSREQUEST REQUESTS AT LEAST 4 WEEKS PRIOR TO THE START DATS OF ETHER [ISLES THAN 4 WEEKS PRIOR TO THE START DATE OF EITHER THE ‘THE CURRENTDATES (OR DESIRED DATES OF CLERKSHIP. ‘CURRENT DATES OR DESIRED DATES OF CLERKSHP. OFFICE OF THE REGISTRAR AUTHORIZATION (CLERKSHIP DIRECTOR APPROVAL C1 Request APPROVED; SPACE AVAILABLE C7 Request APPROVED; SPACE AVAILABLE C7 Request Dentep; NO SPACE AVAILABLE C1 Request ArpROVED; OVERLOAD APPROVED. C1 Reqursr Denied ‘OFRCE OFTHE REGISTRAR SIGNATURE Da CERT DECIR SONATE Date | curnesiur DinscroR: ONCE SIGNED, PLEASE RETURN TO THE OFFICE OF THE REGISTRAR