Adult Congenital Heart Program at Stanford Fellowship Application

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.