Application Form – The University of Alabama Tuscaloosa Family Medicine Residency Program

First Name *

Middle Name

Last Name *

Date of Birth *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Phone *

Email Address *

Attach a recent photo of yourself

Are you a U.S. citizen? *

Yes

Do you require VISA support? *

Yes

What kind of Visa do you have? *

J-1 Physician Visa

H-1B

Permanent Visa

Education

Undergraduate *

Please include the name(s) of the institution(s), the location(s), dates attended, and degree(s) earned.

Medical School *

Please list the name of the medical school, location, and dates attended.

Upload your Medical School Diploma, certificate, or other validation of all your previous training

Residency

Please list residency program(s), location(s), and dates attended.

Medical License

Medical License Number

State that issued your license

Medical License Examiners

Include all scores whether passing or non-passing.
Submit FLEX, USMLE, or COMLEX scores.

Part 1 Date Completed

Part 2 Date Completed

Part 3 Date Completed

Upload your state medical liceneses

Fellowship Application

Why do you want this particular fellowship opportunity and what are your future goals? *

Rural Practice *

I understand that this fellowship requires one year of practice in rural Alabama after the fellowship year.

Upload your Curriculum Vitae *

Previous Practice Experience *

Locations and Dates

Publications

Author, Title, Publication, and Date. Please upload a copy of the title page of any listed publication.

Upload Title Pages of Publications

Honors and Awards Received

Work Expereince Prior to Medical Training

Occupation, Title, and Dates

Are you certified by the E.C.F.M.G.? *

Yes

Which E.C.F.M.G. qualifying exam did you take? *

Dates of E.C.F.M.G. Exams *

Score for Part I *

Score for Part II *

E.C.F.M.G. Certificate Number *

E.C.F.M.G. Certificate valid through *

Have you been placed on any form of discipline (e.g., Letter of Concern, Probation, Suspension, Non-Renewal of contract) during your residency training? *

Yes

Identify the form(s) of discipline and explain why you were disciplined. *

Have you had your privileges revoked? *

Yes

Explain why your privileges were revoked. *

Have you ever been part of a malpractice complaint? *

Yes

Explain your role in the malpractice complaint. *

Are you aware of any limitation which would prevent you from performing the duties of the fellowship? *

References

We require three letters of recommendation; one from your residency director and two additional letters from other people.

Rural Practice Required post Fellowship *

I Agree

I understand that the Behavioral Medicine Fellowship requires the fellow to practice for one year in rural Alabama following the one year fellowship.

Behavioral Health Rotations *

Dates, Location, and Instructor

Behavioral Health Service Coverage *

Volunteer or experience other than residency or moonlighting

Behavioral Health Conferences Attended

Name of Conferences, Dates, and Locations

Behavioral Health Conferences Where You Presented

Name of Conference, Date, and Location.

Upload the Program Where Your Presentation is Listed

References and Supporting Documents

Ask your residency program director, an ER physician who was your preceptor, and a third physician who supervised you in a clinical setting to mail letters of support to the fellowship.

Emergency Medicine Rotations *

Dates, Location, and Instructor

Emergency Medicine Service Coverage *

Volunteer or experience other than residency or moonlighting

Emergency/Family Medicine Conferences Attended

Name of Conferences, Dates, and Locations

Emergency/Family Medicine Conferences Where You Presented

Name of Conference, Date, and Location.

Upload the Program Where Your Presentation is Listed

References and Supporting Documents

Ask three physicians who supervised you in a clinical setting to mail letters of support of your application.

Hospitalist Medicine Rotations *

Dates, Type, Location, and Instructor

Hospitalist Medicine Service Coverage *

Dates and Location of coverage

Hospitalist Medicine Conferences Attended

Name of Conferences, Dates, and Locations

Hospitalist Medicine Conferences Where You Presented

Name of Conference, Date, and Location. Attach

Upload the Program Where Your Presentation is Listed

Personal Statment *

Approval

I certify that the information given or attached is true, accurate, and complete.

Sign your full name; this constitutes an Electronic Signature.

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