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For everyone like me that is applying this year, you may be interested to know that you CAN send in a late 4th letter this year, even though it does not say so in the CAS instructions. I emailed to director of the SF Match who said that they will process a late 4th letter. It sounds like a lot of us planned and scheduled our fourth year rotations around obtaining a 4th letter from an away rotation, so this is good news. Hope this helps!