UT Southwestern - International Visiting Medical Student Application Form

Applicant Info

First Name
Last Name
Passport No
Birth Date
Email
Phone

Item Info

Item Description

Rotation fee (6 maximum)

Malpractice insurance fee

Quantity

Unit Price
(USD)

$25.00

$25.00

Total

Total

Payment Info

Amount ($)

Credit Card Number
CVV2
Expiration Date

Routing Number
Account Number
Account Type
- Checking
- Savings

Billing Contact Info

First Name
Last Name
Billing Address 1
Billing Address 2
City
Province/State
Country
Postal Code

Verify

If you have any questions, please contact the Office of Enrollment Services

Office of Enrollment Services
UT Southwestern Medical Center
5323 Harry Hines Blvd. Dallas, TX 75390-9096
Phone: 214-648-3606 | Fax: 214-648-3289 | [email protected]

Secure Payment Processing