Fellowship Applications

Are you a U.S. citizen?(Required)

Yes

Do you require VISA support?(Required)

Yes

Undergraduate(Required)

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

Medical School(Required)

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(Required)

I have uploaded my validation of previous training to the Validation Box Link below and acknowledge that without it, my application may be voided.

Validation Box Link

Residency

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

Medical License

Medical License Number

State that issued your license

State

Medical License Examiners

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

Part 1 Date Completed

Month

Day

Year

Part 2 Date Completed

Month

Day

Year

Part 3 Date Completed

Month

Day

Year

Upload your state medical licenses(Required)

I have uploaded my state medical licenses to the State Medical Licenses Box Link below and acknowledge that without it, my application may be voided.

Fellowship Application

Upload your Curriculum Vitae(Required)

I have uploaded myCurriculum Vitae to the Curriculum Vitae Box Link below and acknowledge that without it, my application may be voided.

Title Pages of Publications Box Link

Previous Practice Experience(Required)

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 Experience Prior to Medical Training

Occupation, Title, and Dates

Are you certified by the E.C.F.M.G.?(Required)

Yes

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

Yes

Have you had your privileges revoked?(Required)

Yes

Have you ever been part of a malpractice complaint?(Required)

Yes

Are you aware of any limitation which would prevent you from performing the duties of the fellowship?(Required)

Occupation, Title, and Dates

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

I agree

Behavioral Health Rotations(Required)

Dates, Location, and Instructor

Behavioral Health Service Coverage(Required)

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

Program Presentation Listed Box Link

Approval

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

FirstMiddleLast

Sign your full name; this constitutes an Electronic Signature.

CAPTCHA

Emergency Medicine

Emergency Medicine Fellowship Application

Your Information

Name(Required)

FirstLast

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street AddressCityState / Province / RegionZIP / Postal CodeCountry

Phone(Required)

Email(Required)

Attach a recent photo of yourself

Are you a U.S. citizen?(Required)

Yes

Do you require VISA support?(Required)

Yes

What kind of Visa do you have?(Required)

J-1 Physician Visa

H-1B

Permanent Visa

Education

Undergraduate(Required)

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

Medical School(Required)

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(Required)

I have uploaded my previous training to the Training Validation Box Link below and acknolwedge that if I do not upload training validation, my application may be voided.

Residency

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

Medical License

Medical License Number

State that issued your license

State

Medical License Examiners

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

Part 1 Date Completed

Month

Day

Year

Part 2 Date Completed

Month

Day

Year

Part 3 Date Completed

Month

Day

Year

Upload your state medical licenses(Required)

I have uploaded my state medical licenses to the State Medical Licenses Box Link below and acknolwedge that if I do not upload my state medical licenses, my application may be voided.

Fellowship Application

Upload your Curriculum Vitae(Required)

I have uploaded my curriculum vitae to the Curriculum Vitae Box Link below and acknolwedge that if I do not upload my curriculum vitae, my application may be voided.

Title Pages Publications Box Link

Previous Practice Experience(Required)

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 Experience Prior to Medical Training

Occupation, Title, and Dates

Are you certified by the E.C.F.M.G.?(Required)

Yes

Dates of E.C.F.M.G. Exams(Required)

Which E.C.F.M.G. qualifying exam did you take?(Required)

Score for Part 1(Required)

Score for Part 2(Required)

E.C.F.M.G. Certificate Number(Required)

E.C.F.M.G. Certificate valid through(Required)

Month

Day

Year

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

Yes

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

Have you had your privileges revoked?(Required)

Yes

Explain why your privileges were revoked.(Required)

Have you ever been part of a malpractice complaint?(Required)

Yes

Explain your role in the malpractice complaint.(Required)

Are you aware of any limitation which would prevent you from performing the duties of the fellowship?(Required)

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(Required)

Dates, Location, and Instructor

Emergency Medicine Service Coverage(Required)

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

Program Presentation Listed Box Link

Approval

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

FirstMiddleLast

Sign your full name; this constitutes an Electronic Signature.

CAPTCHA

Hospitalist

Hospitalist Medicine Fellowship Application

Your Information

Name(Required)

FirstLast

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street AddressCityState / Province / RegionZIP / Postal CodeCountry

Phone(Required)

Email(Required)

Attach a recent photo of yourself

Are you a U.S. citizen?(Required)

Yes

Do you require VISA support?(Required)

Yes

What kind of Visa do you have?(Required)

J-1 Physician Visa

H-1B

Permanent Visa

Education

Undergraduate(Required)

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

Medical School(Required)

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(Required)

I have uploaded my training validation files and acknowledge that without them, my application may be voided.

Residency

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

Medical License

Medical License Number

State that issued your license

State

Medical License Examiners

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

Part 1 Date Completed

Month

Day

Year

Part 2 Date Completed

Month

Day

Year

Part 3 Date Completed

Month

Day

Year

Upload your state medical licenses(Required)

I have uploaded my state medical license files and acknowledge that without them, my application may be voided.

Fellowship Application

Upload your Curriculum Vitae(Required)

I have uploaded my curriculum vitae files and acknowledge that without them, my application may be voided.

Title Pages of Publications Box Link

Previous Practice Experience(Required)

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 Experience Prior to Medical Training

Occupation, Title, and Dates

Are you certified by the E.C.F.M.G.?(Required)

Yes

Dates of E.C.F.M.G. Exams(Required)

Which E.C.F.M.G. qualifying exam did you take?(Required)

Score for Part 1(Required)

Score for Part 2(Required)

E.C.F.M.G. Certificate Number(Required)

E.C.F.M.G. Certificate valid through(Required)

Month

Day

Year

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

Yes

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

Have you had your privileges revoked?(Required)

Yes

Explain why your privileges were revoked.(Required)

Have you ever been part of a malpractice complaint?(Required)

Yes

Explain your role in the malpractice complaint.(Required)

Are you aware of any limitation which would prevent you from performing the duties of the fellowship?(Required)

Occupation, Title, and Dates

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(Required)

Dates, Location, and Instructor.

Hospitalist Medicine Service Coverage(Required)

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.

Upload the Program Where Your Presentation is Listed

I have uploaded my curriculum vitae files and acknowledge that without them, my application may be voided.

Program Presentation Listed Box Link

Personal Statement(Required)

Approval

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

FirstMiddleLast

Sign your full name; this constitutes an Electronic Signature.

CAPTCHA

Obstetrics

Obstetrics Fellowship Application

Your Information

Name(Required)

FirstLast

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street AddressCityState / Province / RegionZIP / Postal CodeCountry

Phone(Required)

Email(Required)

Are you a U.S. citizen?(Required)

Yes

Do you require VISA support?(Required)

Yes

What kind of Visa do you have?(Required)

J-1 Physician Visa

H-1B

Permanent Visa

Education

Undergraduate(Required)

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

Medical School(Required)

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(Required)

I have uploaded my training validation file(s) at the link below and acknowledge that without it/them, my application may be voided.

State Medical License Box Link

Residency

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

Medical License

Medical License Number

State that issued your license

State

Medical License Examiners

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

Part 1 Date Completed

Month

Day

Year

Part 2 Date Completed

Month

Day

Year

Part 3 Date Completed

Month

Day

Year

Upload your state medical licenses(Required)

I have uploaded my state medical license file(s) at the link below and acknowledge that without it/them, my application may be voided.

Fellowship Application

Why do you want this particular fellowship opportunity and what are your future goals?(Required)

Locations and Dates

Rural Practice

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

I agree

Approval

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

FirstMiddleLast

Sign your full name; this constitutes an Electronic Signature.

CAPTCHA

Pediatrics

Pediatric Fellowship Application

Personal Data

Name(Required)

FirstMiddle InitialLast

Present Address(Required)

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry

Home Phone(Required)

Work Phone(Required)

Cell Phone(Required)

Email Address(Required)

Are you a U.S. citizen?(Required)

Yes

Education

College or University(Required)

City/State(Required)

CityState

Date(Required)

Month

Day

Year

Degree(Required)

College or University

City/State

CityState

Date

Month

Day

Year

Degree

College or University

City/State

CityState

Date

Month

Day

Year

Degree

Advanced Degree School(Required)

City/State(Required)

CityState

Date(Required)

Month

Day

Year

Degree(Required)

Advanced Degree School

City/State

CityState

Date

Month

Day

Year

Degree

Medical School(Required)

City/State(Required)

CityState

Date(Required)

Month

Day

Year

Degree(Required)

Graduate Medical Education

PGY-1

PGY-1(Required)

Hospital(Required)

Address(Required)

CityState

Date(Required)

Month

Day

Year

Type(Required)

Residency

Residency(Required)

Hospital(Required)

Address(Required)

CityState

Date(Required)

Month

Day

Year

Type(Required)

Residency(Required)

Hospital(Required)

Address(Required)

CityState

Date(Required)

Month

Day

Year

Type(Required)

US Medical License Examiners

Part 1 date(Required)

Month

Day

Year

Part 2 date(Required)

Month

Day

Year

Part 3 date(Required)

Month

Day

Year

Previous practice experience(Required)

Pediatric Rotations(Required)

(Dates, Type, Location, Instructor)

Pediatric Coverage(Required)

(Volunteer, research, or experience other than residency/Moonlighting)

Pediatric Conferences (Attended)(Required)

Pediatric Conferences (Presented)(Required)

Please include a copy of the program of any listed presentation(Required)

I have uploaded a copy of the program of any listed presentation and acknowledge that without a copy, my application may be voided.

Listed Program Box Link

Publications(Required)

(Author, Title, Publication, Date – use additional sheets if necessary)

Please include a title page of any listed presentation(Required)

I have uploaded the title page of any listed presentation and acknowledge that without an upload, my application may be voided.

Title Pages of Presentations Listed Box Link

Additional Personal Data

Work Experience Prior to Medical Training(Required)

(Occupation/Title, Dates)

Military Status (U.S.A)(Required)

(Present Status and Service)

Do you hold a reserve Commission?(Required)

Yes

Have you served in the military or U.S.P.H.S.?(Required)

Yes

Have you attended summer training camp?(Required)

Yes

Are you required to attend reserve meetings?(Required)

Yes

Are you required to attend summer training camp?(Required)

Yes

Do you have a military or U.S.P.H.S. commitment?(Required)

Yes

Conferences Attended or Presented (other than Pediatrics)(Required)

Honors and Awards(Required)

Have you ever been placed on probation, suspended from your job duties, residency, training program, had privileges revoked, or been part of a malpractice complaint?(Required)

Yes

If YES, please explain below.(Required)

Are you aware of any limitation which would prevent you from performing the duties of the fellowship for which you are applying?(Required)

6. Are you aware of any limitation which would prevent you from performing the duties of the fellowship for which you are applying? 7. Personal Statement:(Required)

(please do not exceed 750 words)

Section Break

References and Supporting Documents

*Please ask three physicians who have supervised you in a clinical setting to send letters in support of your application. One of these letters should be from residency program director, and another letter from a pediatrician who was your preceptor in a pediatric rotation

*Copies of the following documents are requested: medical school diploma, certificate or other validation of all previous training, copy of present state medical licenses, and curriculum vitae.

*Please note that individual fellowships may require additional information such as letter of recommendation from medical school dean, undergraduate and medical school transcripts, and rotations taken during residency. Contact the individual fellowships you are applying to for further application requirements and deadlines.

Do not send original documents. No documents will be returned

Photocopies of this application will be accepted. However, the signature on each hard copy application must be original.

I certify that the information given or attached is true, accurate and complete. Be advised, any inaccuracies within this application could disqualify your candidacy.(Required)

Yes, I agree.

Applicant Name(Required)

FirstMiddle InitialLast

CAPTCHA

Rural Public Psychiatry

Rural Public Psychiatry Fellowship Application

Your Information

Name(Required)

FirstLast

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street AddressCityState / Province / RegionZIP / Postal CodeCountry

Phone(Required)

Email(Required)

Are you a U.S. citizen?(Required)

Yes

Do you require VISA support?(Required)

Yes

What kind of Visa do you have?(Required)

J-1 Physician Visa

H-1B

Permanent Visa

Education

Undergraduate(Required)

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

Medical School(Required)

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(Required)

I have uploaded my training validation files and acknowledge that without them, my application may be voided.

Residency

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

Medical License

Medical License Number

State that issued your license

State

Medical License Examiners

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

Part 1 Date Completed

Month

Day

Year

Part 2 Date Completed

Month

Day

Year

Part 3 Date Completed

Month

Day

Year

Upload your state medical licenses(Required)

I have uploaded my state medical licenses files and acknowledge that without them, my application may be voided.

Fellowship Application

Upload your Curriculum Vitae(Required)

I have uploaded my curriculum vitae files and acknowledge that without them, my application may be voided.