Center For Aging Research and Clinical Care

Geriatric Fellowship Program

Overview
Program Description
Institutions and Rotations
Program Faculty
Fellowship Training Application

Geriatric Fellowship Program Application Form
for Direct On-line Submission

Proposed year of Admission

(yyyy)

How did you learn about our Fellowship Program?

website journal ad poster

Other:

Full Name

Social Security Number

Current Mailing Address

Current Telephone Numbers

Home:	(xxx-xxx-xxxx)
Beeper:	(xxx-xxx-xxxx)

Permanent Mailing Address

Permanent City, State, Zip

Permanent Telephone Number

(xxx-xxx-xxxx)

Citizenship

Date of Birth

(mm/dd/yyyy)

Birthplace

Email Address

If you are not a citizen of the United States, please answer the following:

a) Are you a U.S. permanent Resident	Yes No
b) What kind of visa do you hold or will hold while you are here?
*A copy of your visa or greencard must be enclosed. Please Note: J1-visa holders are not eligible for this two-year fellowship program.
c) How many dependants will accompany you?
d) If you are in the U.S. on an exchange visitor program, name your present sponsor.
If you are a graduate of a foreign medical school (except Canada): You are required to be certified by the Educational Council for Foreign Medical Graduates. If you are certified, indicate below:
Standard Certificate: Photocopy must be enclosed.	Number
Interim Certificate: Photocopy must be enclosed.	Number
Date of passing ECMFG exam	(mm/dd/yyyy)

Education:
List in reverse chronological order: college/university, graduate and professional schools you have attended.

1	Name of School	Location
	Dates Attended	Major
	Degree	Date Received

2	Name of School	Location
	Dates Attended	Major
	Degree	Date Received

3	Name of School	Location
	Dates Attended	Major
	Degree	Date Received

4	Name of School	Location
	Dates Attended	Major
	Degree	Date Received

Academic honors, scholarships, and other awards you have received:

Post Graduate Training: List sequentially your post-M.D. training.

PGY-1	Dates		Institution
PGY-1	Location		Specialty

PGY-2	Dates		Institution
PGY-2	Location		Specialty

PGY-3	Dates		Institution
PGY-3	Location		Specialty

List all fellowships you have held.

1	Name of Fellowship
1	Institution		Date

2	Name of Fellowship
2	Institution		Date

Board and/or Subspecialty Board Certified:

(number and year)

Licensure: Please provide license number, date issued and state(s).

Are any of your licenses limited or temporary?

No Yes If so, please explain:

Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked?

No Yes If so, please explain:

Have your privileges at any hospital or other facility ever been denied, limited suspended, revoked or not renewed? And/or have you ever been denied membership or a renewal therein or have been subjected to disciplinary proceedings in any hospital or medical organization?

No Yes If so, please explain:

National and State Board examinations:

1	Date		State
1	Number		Pass/Fail

2	Date		State
2	Number		Pass/Fail

Research and Publications:

References:
Please list the names and addresses of the three referring faculty members from whom we can expect to hear from. One must be from the Director of your current or most recent clinical training program.

1	Name:	Title:
	Address:
	Phone:	Email:

2	Name:	Title:
	Address:
	Phone:	Email:

3	Name:	Title:
	Address:
	Phone:	Email:

Personal Statement: Please state the reason for your interest in this program. The statement must describe your purpose, objectives, clinical and research interests and goals. Describe your major area of research interest in Geriatric Medicine and/or Gerontology. In addition, please indicate your long term goals (what would you like to be doing in five to ten years).

Curriculum Vitae

I certify that the information contained in this application, including the statement of purpose, and in the supporting documents is complete and accurate, and I understand that submission of inaccurate information may be sufficient cause for denial of admission or termination of enrollment.


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