Ases orthopaedic Shoulder & Elbow Match Application, 2018-2019 Deadline: Tuesday, November 1, 2016 Personal Data

ASES Orthopaedic Shoulder & Elbow Match Application, 2018-2019

Deadline: Tuesday, November 1, 2016

Personal Data

Name (Last, First, Middle, include degrees, i.e.: MD, MBA, MPH, etc.)      
Address (where you can best be reached) Street/ Apt #:       City/State/Zip:       Country (If outside US):      	Phone:       Cell Phone:       Email:      
Permanent Address (if different from above) Street/ Apt #:       City/State/Zip:       Country (If outside US):      	DOB:       Citizenship if other than US:       Do you currently have the legal right to work in the United States?  Yes  No Type if Visa: J-1  H-1  Other:       Visa#:      

Education/Training

Residency Training Institution I
Full Name of Institution:      	City/State/Country (If outside US):      
Dates Attended from (mm/yy) to (mm/yy) From:       To:      	Program Director:      
	Specialty:      
Residency Training Institution II
Full Name of Institution:      	City/State/Country (If outside US):      
Dates Attended from (mm/yy) to (mm/yy) From:       To:      	Program Director:      
	Specialty:      
Medical (or Osteopathic) School
Full Name of Institution:      	City/State/Country (If outside US):      
Dates Attended from (mm/yy) to (mm/yy) From:       To:      	Degree:      
Undergraduate Education I
Full Name of Institution:      	City/State/Country (If outside US):      
Dates Attended from (mm/yy) to (mm/yy) From:       To:      	Degree/Major:      
Undergraduate Education II
Full Name of Institution:      	City/State/Country (If outside US):      
Dates Attended from (mm/yy) to (mm/yy) From:       To:      	Degree/Major:      
Non-Medical Graduate School (if applicable)
Full Name of Institution:      	City/State/Country (If outside US):      
Dates Attended from (mm/yy) to (mm/yy) From:       To:      	Degree/Major:      

Military Service

Do you have a military service obligation:  YES  NO Dates:       Branch of Service:      

Current or pending deployments:      

DO YOU REQUIRE A MILITARY RELEASE TO COMPLETE THIS FELLOWSHIP?  YES  NO

Licenses/Examinations

I have passed the following examinations: USMLE Step 1: USMLE#: Date:       3-digit score:       2-digit score:       Number of times taken:       USMLE Step 2: Date:       3-digit score:       2-digit score:       Number of times taken:       USMLE Step 3: Date:       3-digit score:       2-digit score:       Number of times taken:      
Medical License (State 1):      	License Number:      
ECFMG (state):      	ECFMG Number:      
Medical License (State 2):      	License Number:      
ECFMG (state):      	ECFMG Number:      
Any suspensions, restrictions, disciplinary actions to your medical license? (please describe)      

Letters of Recommendation

Please submit at least 3 letters of recommendation including 1 from your department chairman and 1 from your program director (if they are different). Do not submit more than 4 letters of recommendation total.

Letter #1
Name & Title:      
Institution Name:      	Institution Address:      
Contact Phone:      	Email:      
Check one:  I have waived access to this letter and have informed the author of this confidentiality.  I desire access to this letter and have informed the author.
Letter #2
Name & Title:      
Institution Name:      	Institution Address:      
Contact Phone:      	Email:      
Check one:  I have waived access to this letter and have informed the author of this confidentiality.  I desire access to this letter and have informed the author.
Letter #3
Name & Title:      
Institution Name:      	Institution Address:      
Contact Phone:      	Email:      
Check one:  I have waived access to this letter and have informed the author of this confidentiality.  I desire access to this letter and have informed the author.
Letter #4
Name & Title:      
Institution Name:      	Institution Address:      
Contact Phone:      	Email:      
Check one:  I have waived access to this letter and have informed the author of this confidentiality.  I desire access to this letter and have informed the author.

I certify that the information in this application is true and complete and that I have not withheld information that might significantly affect my qualifications for fellowship training. I understand that any misrepresentation in this application and its accompanying documents may be cause for immediate termination of my application process or future employment.

I authorize any training program that receives this application to contact any or all of my former employers, educational institutions and/or other persons or organizations who may have information relevant to my application. I understand that any information obtained will be treated as confidential information. I authorize the ASES to use any information I have provided to ASES in any study approved by the ASES Match Committee, provided that no information clearly and uniquely identifiable to me is disclosed in reports resulting from such study. I intend to complete all prerequisites before the start of my residency training.
I understand that any contract or match result will be void if I do not satisfactorily complete my prerequisite training or if I fail to meet other requirements that have been explicitly stated to all applicants.
I will formally withdraw from this match prior to the rank list due date if I accept any position outside the match before the due date. If I match through the ASES Match, I will withdraw from all other competitive matches in post-graduate medicine.
By submitting a rank list, both the applicants’ choices and the program directors’ choices make the match result a binding commitment. Therefore, I understand that the results of the ASES match are binding and must be adhered to.

Signature: Date:      

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