Application

Education
Please include the name(s) of the institution(s), the location(s), dates attended, and degree(s) earned.
Please list the name of the medical school, location, and dates attended.
Please list residency program(s), location(s), and dates attended.
Medical License
Medical License

Include all scores whether passing or non-passing.
Submit FLEX, NBME, or COMLEX scores if applicable.

Fellowship Application
Locations and Dates
Author, Title, Publication, and Date. Please upload a copy of the title page of any listed publication.
Occupation, Title, and Dates

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

I understand that the Behavioral Medicine Fellowship requires the fellow to practice for one year in rural Alabama following the one year fellowship.
Dates, Location, and Instructor
Volunteer or experience other than residency or moonlighting
Name of Conferences, Dates, and Locations
Name of Conference, Date, and Location.

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.

Dates, Location, and Instructor
Volunteer or experience other than residency or moonlighting
Name of Conferences, Dates, and Locations
Name of Conference, Date, and Location.

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

Dates, Type, Location, and Instructor
Dates and Location of coverage
Name of Conferences, Dates, and Locations
Name of Conference, Date, and Location. Attach
Approval
Sign your full name; this constitutes an Electronic Signature.
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