Section of Cardiology

ADVOCATE ILLINOIS MASONIC MEDICAL CENTER

Clinical Cardiac Electrophysiology Training Program -PGY-7
836 West Wellington Avenue, MOC/803, Chicago, Illinois 60657, Telephone [phone]

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:

• 
  An Advocate Illinois Masonic Medical Center application form;
  
• 
  An official medical school transcript (if AMG, with embossed school seal; if IMG, notarized photocopy;
  
• 
  Copy of test scores as applicable; USMLE or COMLEX
  
• 
  Letter of status from your allopathic/osteopathic medical school OR a notarized photocopy of your medical school diploma;
  
• 
  If licensed, a photocopy of any/all state/province/country medical licenses held;
  
• 
  If permanently licensed, a photocopy of your state controlled substance and Federal DEA registrations;
  
• 
  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:
  
• 
  Current curriculum vitae;
  
• 
  Photocopies of certificates/letters that document completion of any/all previous residency training;
  
• 
  If IMG, a photocopy of your Standard ECFMG Certificate (marked “Valid Indefinitely” if issue before 2002)
  

Rev. 8/07