Colon & Rectal Surgery at the University of Louisville -- Clinical Fellowship Application

Clinical Fellowship Application

If you would like to apply for a clinical fellowship, please fill out the following application.

Note: Since we cannot guarantee the privacy of electronic transmissions at this time, we ask that you complete the application, print it out and submit it by mail or by fax.

Mail to: Susan Galandiuk, M.D. Program Director Section of Colon and Rectal Surgery	University of Louisville Department of Surgery 550 South Jackson St., Louisville, KY 40202
Fax to: (502) 852-8915
Clinical Fellowship Application Form Section of Colon & Rectal Surgery University of Louisville


Position Beginning (month/year):
Name (last/first/middle):

Medical Education (Residency)
Medical School:
City:
State/Country:
Month/Year of Matriculation at Medical School:
Month/Year of Anticipated Graduation:
Electives Completed/Planned(Place a "P" after planned senior electives.):

Honors/Awards:

Graduate Education (Medical School)
Graduate School (name):
Dates Attended (e.g., 9/99 to 6/00):
Degree (if any):
Area of Study:
City & State/Country:

Graduate School (name):
Dates Attended (e.g., 9/99 to 6/00):
Degree (if any):
Area of Study:
City & State/Country:

Undergraduate Education (Undergraduate College/s)
Dates Attended (e.g., 9/90 to 6/94):
Degree (if any):
Major(s):
Name of School:
City & State/Country:

Dates Attended (e.g., 9/90 to 6/94):
Degree (if any):
Major(s):
Name of School:
City & State/Country:

Service Obligations (National Health Service Corps, Armed Forces Scholarship, State Progams, etc.)
	I am not required to fulfill any service obligations.
	I am committed to fulfill a service obligation.
Service to begin on (date):
Number of Years Committed:

Other Required Data
Social Security Number:
ECFMG Registration (if applicable):
Shall participate in NRMP match (indicate "yes" or "no"):
NRMP Code (enter "pending" if unknown):
Number of Dependents:
Citizenship (e.g., USA, United Kingdom, India):
Visa Status, if applicable (indicate permanent or temporary):
Specify "J-1" or "H-1":

Present Address (Street/City/State/Zip Code/Country):
Present Daytime Phone Number:
Present Evening Phone Number:
Permanent Address (or name of person through whom you can be contacted). Include: Street/City/State/Zip Code/Country:
Phone Number

I plan to take the examinations checked below before I begin the Graduate Medical Education program for which I am now applying.
	USMLE, STEP I
	USMLE, STEP II
	USMLE, STEP III

I have already passed the following examinations on the dates indicated:
NBME, Part I (date):
NBME, Part II (date):
NBME, Part III (date):
USMLE, STEP I (date):
USMLE, STEP II (date):
USMLE, STEP III (date):
FLEX (date & State(s) of licensure):

List any additional examinations passed (FMGEMS, DAY 1; FMGEMS, DAY 2; VQE, DAY 1; VQE, DAY 2; ECFMG Medical Science Exam): Interview Scheduling
Most Convenient Time (i.e., August 20 to August 24):
Second Time Frame:

Letters of Reference (requested from the following individuals):
Name:
Address:
Name:
Address:

Name:
Address:
	I hereby waive access to the above letters and will so inform the authors.
	I desire access to the above letters and will so inform the authors.
Signature:
Date:

Personal Statement (use for additional information, if necessary) I have read and I understand the instructions for the completion of this application. I certify that the information submitted on these application materials is complete and correct to the best of my knowledge. I understand that any false or missing information may disqualify me for this position.
Signature:
Date:

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