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This rotation fee is due no later than 2 weeks after you have been offered a spot. If you do not pay by that date,
your rotation may be canceled. Students who who have their fee waived or drop more than 4 weeks before their
scheduled start date will have their payment fully refunded.

Section 1 - Student Information

Last Name

First Name

Email Address

Date of Birth (MM/DD/YYYY)

Home Medical School

Admitted Rotation Dates

Admitted Elective Name

Section 2 - Payment Information

Rotation Fee:

Total Amount Due:

Payment Info

Payment details

Card Number

Expiration Date

Security Code (CVV)

Billing Info

Company Name

First Name

Last Name

Address 1

Address 2

City

State

Zip/Postal Code

Country

Email Address

Phone #

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Payment Info

Payment details

Billing Info

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