fellowship program application · experience please add your additional experience. clinical and...

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Fellowship Program Application

Name: _______________________________ ___________________________________________________________________________________________________________ First MI Last Last for digits of SSN: __ __________________ Citizenship: ⎕ U.S. ⎕ Resident Alien ⎕ Non-Resident Alien Citizenships: ____________________________________________________________ Visa/Employment Authorization (J-1): ⎕ YES ⎕ NO Home Phone #: (_______) _________ - ________ ___ Cell Phone #: (_______) _________ - ____________ Work Phone #: (_______) _________ - ___________ ______ Permanent Address: _______________________________________________________________________________________________________________________________________ City: ____________________________________ State: ________________ Zip: _______________ County: ___________________ Country: ________________ ________ Current Address: ____________________________________________________________________________________________________________________________________________ City: ____________________________________ State: ________________ Zip: _______________ County: ___________________ Country: ________________ ________ Additional Contact Information (E-mail):_______________ _________________________________________

Match Information NRMP Match Information: (All applicants must participate in NRMP) _________________________________________________________________________________ USMLE (Must be completed and passed before the date of hire): STEP 1 Passed: ⎕ YES ⎕ NO Score: ___________________________________ STEP 2 Passed: ⎕ YES ⎕ NO Score: ___________________________________ STEP 3 Passed: ⎕ YES ⎕ NO Score: ___________________________________ ACLS (Advanced Cardiovascular Life Support) certified in USA: ⎕ YES ⎕ NO Expiration date: ________________________ PALS (Pediatric Advanced Life Support) certified in USA: ⎕ YES ⎕ NO Expiration date: ________________________ BLS certified in USA: ⎕ YES ⎕ NO Expiration date: ________________________

Biographic Information (Optional) Gender: ____________________________________ Birth Place: _____________________________________________________ Birth date: _____________________________ How do you self-identify? Please select all that apply (if you prefer not to self-identify, please ignore this section). ⎕ Hispanic, Latino or of Spanish origin ⎕ Columbian ⎕ Argentinean

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⎕ Cuban ⎕ Dominican ⎕ Mexican/Chicano ⎕ Peruvian ⎕ Puerto Rican ⎕ Other Hispanic _______________________________ ⎕ American Indian or Alaskan Native ⎕ Tribal affiliation ______________________________ ⎕ Asian ⎕ Bangladeshi ⎕ Korean ⎕ Cambodian ⎕ Laotian ⎕ Chinese ⎕ Pakistani ⎕ Filipino ⎕ Taiwanese ⎕ Indian ⎕ Vietnamese ⎕ Indonesian ⎕ Japanese ⎕ Other Asian: _________________________ ⎕ Black or African American ⎕ African American ⎕ Afro-Caribbean ⎕ African ⎕ Other Black: __________________________ ⎕ Native Hawaiian or Pacific Islander ⎕ Guamanian ⎕ Native Hawaiian ⎕ Samoan ⎕ Other Pacific Islander: ________________________________ ⎕ White ⎕ Other: _____________________________________________________________

Language Fluency What languages do you speak? Select all that apply. For each language that you select, including English, you will be asked to rate your proficiency in that language using the following guidelines: Native/Functionally Native Advanced Good Fair Basic ⎕Albanian ⎕ French ⎕ Mande ⎕ Swahili ⎕American Sign Language ⎕ French Creole ⎕ Marathi ⎕ Swedish ⎕Amharic ⎕ German ⎕ Mon-Khmer, Cambodian ⎕ Syrian ⎕Arabic ⎕ Greek ⎕ Navajo ⎕ Tagalog ⎕Armenian ⎕ Gujarati ⎕ Nepali ⎕ Tamil ⎕Bantu ⎕ Hebrew ⎕ Norwegian ⎕ Telugu ⎕Bengali ⎕ Hindi ⎕ Patois ⎕ Thai ⎕Bulgarian ⎕ Hmong ⎕ Pennsylvania Dutch ⎕ Tongan ⎕Burmese ⎕ Hungarian ⎕ Persian ⎕ Turkish ⎕Cajun ⎕ Ilocano ⎕ Polish ⎕ Ukrainian ⎕Chinese ⎕ Indonesian ⎕ Portuguese ⎕ Urdu ⎕Croatian ⎕ Italian ⎕ Punjabi ⎕ Vietnamese ⎕Cushite ⎕ Japanese ⎕ Romanian ⎕ Yiddish ⎕Czech ⎕ Kannada ⎕ Russian ⎕Danish ⎕ Korean ⎕ Samoan ⎕Dutch ⎕ Kru, Ibo, Yoruba ⎕ Serbian ⎕English ⎕ Laotian ⎕ SerboCroatian ⎕Finnish ⎕ Lithuanian ⎕ Slovak ⎕Formosan ⎕ Malayalam ⎕ Spanish/Spanish Creole



Military Information Are you committed to fulfill a U.S. military active duty service obligations/deferments? ⎕ YES ⎕ NO If yes, number of years remaining _______________________ Branch __________________________________________________________________ Do you have any other service obligations? (e.g.- Military Reserves, Public Health/State programs, etc.) ⎕ YES ⎕ NO If yes, describe ____________________________________________________________________________________________________________________________________

Additional Information Hobbies & Interests __________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________

Higher Education This section allows multiple entries for each Undergraduate and Graduate School you have attached. Since most non-U.S. educational systems do not follow the U.S. model, almost all students and graduates of international schools will indicate “None”. ⎕ None ENTRY 1

Institution__________________________________________________________________________________________________________________________________________ Location: __________________________________________________________________________________________________________________________________________ Education Type: __________________________________________________________________________________________________________________________________ Field of Study: ____________________________________________________________________________________________________________________________________ Degree expected or earned: _____________________________________________________________________________________________________________________

Dates of Attendance: From Month ______________________ From Year: ___________________ To Month: _______________________ To year: ___________________ ENTRY 2

Institution__________________________________________________________________________________________________________________________________________ Location: __________________________________________________________________________________________________________________________________________ Education Type: __________________________________________________________________________________________________________________________________ Field of Study: ____________________________________________________________________________________________________________________________________ Degree expected or earned: _____________________________________________________________________________________________________________________

Dates of Attendance: From Month ______________________ From Year: ___________________ To Month: _______________________ To year: ___________________



Medical Education This section allows entries for each Medical School you have attended. ENTRY 1

Country: ___________________________________________________________________________________________________________________________________________

Institution: ________________________________________________________________________________________________________________________________________

Degree: ___________________________________________________________________________________________________________________________________________

Degree Month: _______________________________________ _ Degree Year: _______________________________________________________________ Dates of Education: From Month ______________________ From Year: ___________________ To Month: _______________________ To year: ___________________ ENTRY 2

Country: ___________________________________________________________________________________________________________________________________________

Institution: ________________________________________________________________________________________________________________________________________

Degree: ___________________________________________________________________________________________________________________________________________

Degree Month: _______________________________________ _ Degree Year: _______________________________________________________________ Dates of Education: From Month ______________________ From Year: ___________________ To Month: _______________________ To year: ___________________

Additional Information Membership in Honorary ____________________________________________________________________________________________________________________________________ Professional Society _________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ Medical School Awards ______________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ Other Awards/ Accomplishments __________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________

Experience

Training Please add any current or prior D.O. Internship, D.O. Residency, and M.D. Residency or M.D. Fellowship in which you have trained, regardless of length of time spent in the training. ⎕ None



ENTRY 1

Type of Training: __________________________________________________________________________________________________________________________________ Specialty: __________________________________________________________________________________________________________________________________________ Institution/Program: ______________________________________________________________________________________________________________________________ Country: ____________________________________________________________________________________________________________________________________________ State/Province: ___________________________________________________________________________________________________________________________________ City: ________________________________________________________________________________________________________________________________________________ Program Director: _________________________________________________________________________________________________________________________________ Supervisor: ________________________________________________________________________________________________________________________________________

⎕ Chief Resident

Dates of Residency/ Fellowship

From Month ______________________ From Year: ___________________ To Month: _______________________ To year: ______________________

Reason for Living _______________________________________________________________________________ ___________________________________________________________________________________________ ENTRY 2

Type of Training: __________________________________________________________________________________________________________________________________ Specialty: __________________________________________________________________________________________________________________________________________ Institution/Program: ______________________________________________________________________________________________________________________________ Country: ____________________________________________________________________________________________________________________________________________ State/Province: ___________________________________________________________________________________________________________________________________ City: ________________________________________________________________________________________________________________________________________________ Program Director: _________________________________________________________________________________________________________________________________ Supervisor: ________________________________________________________________________________________________________________________________________

⎕ Chief Resident

Dates of Residency/ Fellowship


Reason for Living _______________________________________________________________________________ ___________________________________________________________________________________________



Experience Please add your additional experience. Clinical and Teaching experience should be treated as Work experience. Include all unpaid extra-curricular activities and committees you have served on as a Volunteer experiences. ⎕ None ENTRY 1

Experience Type: __________________________________________________________________________________________________________________________________ Organization: ______________________________________________________________________________________________________________________________________ Position: ___________________________________________________________________________________________________________________________________________ Supervisor: ________________________________________________________________________________________________________________________________________ Country: ___________________________________________________________________________________________________________________________________________ State/Province: ____________________________________________________________________________________________________________________________________ City: ________________________________________________________________________________________________________________________________________________ Average Hours/Week: ____________________________________________________________________________________________________________________________ Description: ________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________ Dates of Experience


Reason for Living _______________________________________________________________________________ ___________________________________________________________________________________________ ENTRY 2

Experience Type: __________________________________________________________________________________________________________________________________ Organization: ______________________________________________________________________________________________________________________________________ Position: ___________________________________________________________________________________________________________________________________________ Supervisor: ________________________________________________________________________________________________________________________________________ Country: ___________________________________________________________________________________________________________________________________________ State/Province: ____________________________________________________________________________________________________________________________________ City: ________________________________________________________________________________________________________________________________________________ Average Hours/Week: ____________________________________________________________________________________________________________________________ Description: ________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________



_______________________________________________________________________________________________________________________________________________________ Dates of Experience


Reason for Living _______________________________________________________________________________ ___________________________________________________________________________________________

Additional Questions Was your medical education/training extended or interrupted? ⎕ YES ⎕ NO If yes, please explain any interruptions ____________________________________________________________________________________________________________________ >30 days in education or training ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

Licensure Please add an entry for any of your State or Country medical licenses. ⎕ None ENTRY 1

Country/State: _____________________________________________________________________________________________________________________________________ License Type: ______________________________________________________________________________________________________________________________________ License Number: ___________________________________________________________________________________________________________________________________ Expiration Month: _________________________________________________________________________________________________________________________________ Expiration Year: ___________________________________________________________________________________________________________________________________

ENTRY 2

Country/State: _____________________________________________________________________________________________________________________________________ License Type: ______________________________________________________________________________________________________________________________________ License Number: ___________________________________________________________________________________________________________________________________ Expiration Month: _________________________________________________________________________________________________________________________________ Expiration Year: ___________________________________________________________________________________________________________________________________



Additional Information Has your medical license ever been suspended/revoked/voluntarily terminated? ⎕ YES ⎕ NO If yes, please explain; ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Have you been named in malpractice case? ⎕ YES ⎕ NO If yes, please explain: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Is there anything in your past history that would limit your ability to be licensed ⎕ YES ⎕ NO or would limit your ability to receive hospital privileges? If yes, please explain: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Have you ever been convicted of a misdemeanor in the United State or any other country? ⎕ YES ⎕ NO If yes, please explain: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Have you ever been convicted of a felony in the United State or any other country? ⎕ YES ⎕ NO If yes, please explain: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Are you able to carry out the responsibilities of a resident or a fellow in the specialties and at the specific training programs to which you are applying, including the functional requirements, cognitive requirements, interpersonal and communication requirements with or without reasonable accommodations? ⎕ YES ⎕ NO ⎕ NO RESPONSE If yes, please explain: ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Are you Board Certified? ⎕ YES ⎕ NO If yes, Board Name: ____________________________________________________________________________________________________________________ DEA Registration Number: __________________________________________________________________________________________________________________________________



Publications Add an entry for each of your publications.

Peer Reviewed Journal Articles/Abstracts

Journal Article(s)/Abstract(s) Title: _____________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________ Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Name: _________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Med-Line Unique Identifier (PMID): _______________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Volume: _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Issue Number: _____________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Pages: _______________________________________________________________________________________________________________________________________________ Month: ____________________________________________________________ Year: ___________________________________________________________________________ Peer Reviewed Journal Articles/Abstracts (Other than Published) Journal Article(s)/Abstract(s) Title: _____________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Name: _________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Status: ________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Month: ____________________________________________________________ Year: ___________________________________________________________________________



Peer Reviewed Book Chapter Chapter Title: _____________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Name of Book: _____________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Editor(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publisher: __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Pages: _______________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Country: ____________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ State/Province: ____________________________________________________________________________________________________________________________________ City: ____________________________________________________________________________________________ Year: ______________________________________________ Scientific Monograph Monograph Title: __________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Publication Name: _________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Volume: ____________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Issue Number: _____________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Editors: _____________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publisher: __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Year: ______________________________________________



Other Articles Title of Other Article: ______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Name: _________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Date: __________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Oral Presentation Oral Presentation Title: ___________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Author(s)/Presenter(s): __________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Event/Meeting: ____________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Country: ____________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ State/Province: ____________________________________________________________________________________________________________________________________ City: _________________________________________________________________________________________________________________________________________________ Month: ____________________________________________________________ Year: ___________________________________________________________________________ Peer Reviewed Online Publication Online Publication Title: __________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ URL: _________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Date: __________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________



Non Peer Reviewed Online Publication Online Publication Title: __________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Author(s): __________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ URL: ________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________ Publication Date: __________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________

Personal Statement Please submit your personal statement and outline your motivation/interest to pursue training in Transplant Surgery (1 page).

Additional Documentations Please submit the following:

3 reference/recommendations letters USMLE step 1, 2, 3 certificates ECFMG certificate Personal Statement Completion of Training Certification: Medical School

Surgical/Urology Residency Letter of Good Standing if currently in Surgical Practice.


fellowship program application · experience please add your additional experience. clinical and...

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