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.



 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



Degree(s) Received

Major Field

Minor Field




Grade Pt Ave


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



Expiration Date





Expiration Date





Expiration Date



Research Experience:





Research Topic






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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