Clinical Cardiac Electrophysiology Training Program -PGY-7
836 West Wellington Avenue, MOC/803, Chicago, Illinois 60657, Telephone (773) 296-8260
APPLICATION – GRADUATE MEDICAL EDUCATION
Type or Print Neatly Using Black Ink
Date_____________________
Office Use Only
App. Rec’d ________________
Staple or Paste Interview__________________
Recent Photograph Here Complete __________________
Print name on Back of Photograph ECFMG ___________________
Training
To Begin Employment Eligible________
Name in Full
Last First MI
Mailing Address
Street City State Zip Country
Permanent Address
Street City State Zip Country
Area Code Home ( ) Social Security Number
and Telephone Work ( ) E-mail Address . .
Number Cell ( )
Birthday Birthplace
Citizenship United States Other (specify)
Visa Status (if applicable) Immigrant (permanent)
Nonimmigrant (temporary) Specify: J-1 Other
If Other, Explain:
Enclose copy of visa • Date issued No.
Alien Number (if available)
ACADEMIC TRAINING
Undergraduate Degree From To
Graduate (if applicable) Degree From To
Medical School Degree From To
Residences and Fellowships Certificate From To
Yes No Yes No Yes No
Current Position (if different from above)
Medical School
Rank in class (if available) If class is ranked, provide documentation
Honors (graduate and undergraduate)
Professional organizations and activities
Language Proficiencies
Conversational
Written
Licensure (please circle one) Temporary Permanent
State Date License Number
UNITED STATES MEDICAL LICENSING EXAM (USMLE)
Part I-score Part II -score Part III-score
ECFMG CERTIFICATE
Type Number Date
ABIM BOARD CERTIFIED? (circle one) Yes or No
Certificate Number Date
Are you now under contract with any other hospital for the coming academic year? Yes or No
(circle one)
Are you enrolled in the NRMP/MSMP? (circle one) Yes or No
If so, Number
Tentative long-range training and practice plans
I certify that all information included in this application and accompanying documents is accurate.
Signature
Date
A Clinical Cardiac Electrophysiology Fellowship Application Includes ALL of the Following Documents:
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An Advocate Illinois Masonic Medical Center application form;
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An official medical school transcript (if AMG, with embossed school seal; if IMG, notarized photocopy;
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Copy of test scores as applicable; USMLE or COMLEX
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Letter of status from your allopathic/osteopathic medical school OR a notarized photocopy of your medical school diploma;
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If licensed, a photocopy of any/all state/province/country medical licenses held;
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If permanently licensed, a photocopy of your state controlled substance and Federal DEA registrations;
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Three letters of recommendation; one letter must be from your from Cardiovascular Disease Fellowship Program Director, recent services, places of employment or training, chairman under whose direction you have worked, colleagues, etc. These letters must be sent directly to the director of the program to which you are applying:
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Current curriculum vitae;
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Photocopies of certificates/letters that document completion of any/all previous residency training;
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If IMG, a photocopy of your Standard ECFMG Certificate (marked “Valid Indefinitely” if issue before 2002)
Rev. 8/07
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