Adult Congenital Heart Program at Stanford Fellowship Application



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Adult Congenital Heart Program at Stanford Fellowship Application



Fellowship Training Program - APPLICATION




Name (Last, First, Middle Initial)

     


Date of Application

     


Home Address (Street/P.O. Box, City, ST, Zip)

     


Work Address (Street/P.O. Box, City, ST, Zip)

     


Home Telephone

     


Work/Lab Telephone

     


Work/Lab Fax

     


Email Address

     


Your Dept.

     


Gender

 Female  Male



Birthdate (mm/dd/yy)

     




Citizenship:  US Citizen  Permanent Resident of US

 Foreign National of ___________________ (Country)



Education – After High School

(Indicate all academic and professional education.

For foreign degrees, give US equivalent.)

Name of Institution, Department

and Location



Attendance

Mo/Yr


Degree(s) Received

Major Field

Minor Field



From

To

Degree

Grade Pt Ave

Mo/Yr

Baccalaureate Degree


     

     

     

     

     


     

     

     

Masters Degree


     

     

     

     

     


     

     

     

Medical Degree


     

     

     

     

     


     

     

     

Additional Doctorate Degree


     

     

     

     

     


     

     

     






















International Medical Graduate

1. If you are a graduate of an international medical school (except Canada), you are required to be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). Please provide a copy of your ECFMG certificate.

2. If not a U.S. citizen, what type of visa will you hold while you are here?

3. Do you hold permanent immigrant status in the United States?

If yes, please attach a copy of green card or approval letter.

4. Are you currently in the United States on a Temporary Visa (i.e. J-1, H-1, F-1)?

If yes, attach a copy of your current DS-2019 (if applicable).




Medical Licensure and Examinations
















State

Number

Expiration Date

Permanent

Limited
















State

Number

Expiration Date

Permanent

Limited
















State

Number

Expiration Date

Permanent

Limited




Research Experience:


Institution

     


Advisor

     


Research Topic

     


Dept.


     

Dates


     




Other Relevant Experience:

     




List all Academic Honors, including Fellowships and Scholarships (or append CV):

     



List all Publications (or append CV):



     


Date____________________ Signature __________________________________________________ INSTRUCTIONS: (Please type or print)

Application for clinical training is due by October 1, the year prior to start of training.
Materials must include:

  1. Completed fellowship application

  2. Curriculum vitae and bibliography

  3. Statement of professional and investigative interests (limit: one page)

  4. List of references from whom you are requesting letters

  5. A small photograph

  6. Three letters of recommendation mailed directly to Administrative Coordinator: one from the Chief of your present service and two others most familiar with your medical career and qualifications.

  7. Medical School Transcript. A translation must be provided if in a language other than English.

  8. Copies of United States Medical Licensing Exam (USMLE) scores or Medical Council of Canada (MCC) scores.

  9. ECFMG Certificate if you are a graduate of medical school outside of the United States or Canada.


Mail applications to:

Joyce Hages

870 Quarry Road,

Cardiovascular Medicine

Stanford, CA 94305
LICENSURE: California law requires that all fellows hold a state license or exemption from licensure for graduates of foreign medical schools outside Canada or U.S. Territories. Those who do not have such a license must take and pass the next examination following commencement of service, or obtain licensure by reciprocity with National boards or another state.
California’s minimum requirements are: Each applicant for licensure shall document completion of “an allopathic medical curriculum in a medical school or schools which extend over a period of at least four (4) academic years totaling at least thirty-six (36) months of clinical rotations, including all core clinical rotations.” For further information write: Licensing Division, California Board of Medical Quality Assurance, 1430 Howe Ave. Sacramento, CA 95825.


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