Fellowship Application

Please gather all relevant information before filling out this form in order to submit it.

Application Packet Checklist

USMLE Step 1 and/or COMLEX Level 1 Score and Date passed (USMLE/Comlex 2 and 3 if applicable) in PDF format
Updated Curriculum Vitae (CV) in PDF format
Include cover letter and/or personal statement in PDF format
Check with the fellowship director or coordinator whether there are other items that should be included
Include photo in JPEG format
Please leave field empty (blank) if a question does not apply to you

Applicant Data

Applicant:

Fellowship Application Type:

Start Date:

Expected Graduation Date:

First Name:

Last Name:

Middle Name:

Preferred Email:

Present Address:

Street Address [Line 1]:

Street Address [Line 2]:

City:

State:

Zip Code:

Country:

Permanent Address:

Street Address [Line 1]:

Street Address [Line 2]:

City:

State:

Zip Code:

Country:

Telephone:

Phone Number:

Work:

Mobile Number:

Fax:

Citizenship:

Country of Citizenship:

Visa Status:

Education

Undergraduate School:

Start Date:

Completion Date:

Educational Institution:

City:

State:

Country:

Major:

Degree:

Graduate School:

Start Date:

Completion Date:

Educational Institution:

City:

State:

Country:

Major:

Degree:

Medical School:

Start Date:

Completion Date:

Educational Institution:

City:

State:

Country:

Major:

Degree:

Residency:

Start Date:

Completion Date:

Educational Institution:

City:

State:

Country:

Area of Training (AP, CP, AP/CP, other)

Post-Residency Fellowship:

Start Date:

Completion Date:

Educational Institution:

City:

State:

Country:

Area of training:

Other GME, if applicable:

Start Date:

Completion Date:

Educational Institution:

City:

State:

Country:

Area of training:

Other Experience

In chronological order, list other educational experiences, jobs, military service or training that is not accounted for above.

Start Date:

Completion Date:

Job or Experience Title:

Job or Experience Description:

Educational Institution:

City:

State:

Country:

Start Date:

Completion Date:

Job or Experience Title:

Job or Experience Description:

Educational Institution:

City:

State:

Country:

Start Date:

Completion Date:

Job or Experience Title:

Job or Experience Description:

Educational Institution:

City:

State:

Country:

National Boards

Please indicate national board examination dates and results received.

USMLE Step 1

Date passed:

Score:

Percentile:

USMLE Step 2

CK - Date passed:

CK - Score (optional):

Percentile:

CS - Date passed:

CS - Score (optional):

Percentile:

USMLE Step 3

Date passed:

Score (optional):

Percentile:

For graduates of international medical schools, are you ECFMG-certified?

YesNo

COMLEX Level 1

Date passed:

Score:

Percentile:

COMLEX Level 2

Date passed:

Score (optional):

Percentile:

COMLEX Level 3

Date passed:

Score (optional):

Percentile:

Medical Licensure

Please list any states in which you hold a license to practice medicine. Please provide a license number. If an application is pending in a state, please write “pending.”

Country:

State:

License Number:

License Issued Date:

Active:

Country:

State:

License Number:

License Issued Date:

Active:

Have you ever been reprimanded, or had your license suspended or revoked in any of these states?

YesNo

Have you ever been named in (and/or had a judgment against you) in a medical malpractice legal suit?

YesNo

Board Certification

Please indicate any areas of board certification.

Certifying Board Organization:

Specialty:

Date Issued:

Certifying Board Organization:

Specialty:

Date Issued:

Certifying Board Organization:

Specialty:

Date Issued:

Letters of Recommendation and/or References

Please list the individuals who will write your letters of recommendation. At least three are required.

Reference #1

First Name:

Last Name:

Degree(s):

Title:

Institution:

Phone Number:

E-Mail:

Street Address [Line 1]:

Street Address [Line 2]:

City:

State:

Zip Code:

Country:

Reference #2

First Name:

Last Name:

Degree(s):

Title:

Institution:

Phone Number:

E-Mail:

Street Address [Line 1]:

Street Address [Line 2]:

City:

State:

Zip Code:

Country:

Reference #3

First Name:

Last Name:

Degree(s):

Title:

Institution:

Phone Number:

E-Mail:

Street Address [Line 1]:

Street Address [Line 2]:

City:

State:

Zip Code:

Country:

Attached Documents

Photo

Drag and drop files here to upload or click to select a file (Maximum 1 file, 64 MB each)

Curriculum Vitae - CV

Drag and drop files here to upload or click to select a file (Maximum 1 file, 64 MB each)

Cover Letter and/or Personal Statement

Drag and drop files here to upload or click to select a file (Maximum 1 file, 64 MB each)

USMLE Scores (All documents will be added to the Complete Application PDF)

Drag and drop files here to upload or click to select a file (Maximum 8 files, 64 MB each)

Additional Text Attachments (Honors and Awards, Publications and Presentations, Memberships and Leadership/Research Experience)

Honors and Awards
(if explicitly listed on CV, include highlights here with reference to location on CV)

Publications and Presentations
(if explicitly listed on CV, include highlights here with reference to location on CV)

Memberships and Leadership/Research Experience
(if explicitly listed on CV, include highlights here with reference to location on CV)

Signature

I hereby certify that all of the information on this application is accurate, complete, and current to the best of my knowledge, and that this application is being made for serious consideration of training in the fellowship indicated. I understand that accepting more than one fellowship position constitutes a violation of professional ethics and may result in the forfeiture of all positions.

Signature:

Date: