Thank you for your interest in the Baylor College of Medicine, Baylor St. Luke's Medical Center Electrophysiology Fellowship Program.

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1 Cardiology Education 6720 Bertner Avenue (MC 1-133) Houston, Texas / Fax 832/ September 2015 Dear Applicant: Thank you f your interest in our program. Please find attached the application and infmation concerning the Bayl College of Medicine Clinical Cardiac Electrophysiology Program at Bayl St. Luke's Medical Center, Home of the Texas Heart Institute, f July Enclosed is an application and release fm that are to be completed and returned to the address shown below. You must also provide: 1) three letters of recommendation (one from your Cardiovascular Training Program Direct and two from physicians with whom you have wked during your residency); 2) a current curriculum vitae; 3) a personal statement; 4) one small passpt style photograph of yourself and, 5) one (1) copy of your medical school diploma which bears an iginal notary seal (with a statement that it is a true copy of the iginal document). International Medical Graduates must also complete and return the Visa Status Questionnaire and provide one (1) notarized copy (with statement) of their valid ECFMG certificate, Ministry of Health letter (f J1 Applicants), official Medical School transcript, and Diploma. We do not accept H1B visa applicants. When all of these documents have been received, your file will be referred to the Fellowship Review Committee. Please note our application deadline is January 15, Upon the Committee's recommendation, you will be contacted to interview. Appointment to our training program is contingent upon meeting the requirements of the Texas State Board of Medical Examiners to obtain a physician-in-training permit, a valid Texas medical license. Your application and required suppting documents, CV, release fm, and photographs should be directed to: Codinat, Cardiology Fellowship Program Bayl St. Luke's Medical Center 6720 Bertner, MC Houston, Texas Letters of recommendation should be addressed and directed to: Mohammad Saeed, M.D. Direct, Clinical Cardiac Electrophysiology Program Bayl St. Luke's Medical Center / Texas Heart Institute 6720 Bertner, MC Houston, Texas Thank you f your interest in the Bayl College of Medicine, Bayl St. Luke's Medical Center Electrophysiology Fellowship Program. Sincerely, Codinat, Cardiology Fellowship Program Enclosures

2 All applications and suppting documents must be postmarked no later than January 15, PLEASE PRINT AND USE AS CHECK-LIST FOR YOUR APPLICATION PACKET BAYLOR COLLEGE OF MEDICINE/BAYLOR ST. LUKE S MEDICAL CENTER ELECTROPHYSIOLOGY FELLOWSHIP APPLICATION REQUIRED DOCUMENTS FOR FELLOWSHIP APPLICATION UNITED STATES MEDICAL GRADUATES (USMG's) Application Personal Statement Curriculum Vitae One (1) copies of your Medical School Diploma which bears an iginal notary seal (with the statement This is a true copy of the iginal document ) Three (3) Letters of Recommendation One (1) Passpt-Style Photograph INTERNATIONAL MEDICAL GRADUATES (IMG's) Application Personal Statement Curriculum Vitae **One (1) Medical College Diploma (TITULO F Mexican College Graduates) Fifth Pathway Certificate which bears an iginal notary seal (with the statement This is a true copy of the iginal document ) **One (1) Valid ECFMG (Valid Indefinitely) Document which bears an iginal notary seal (with the statement This is a true copy of the iginal document ) Interim Letter Current, Non-Restricted License to Practice Medicine from Another State (USA Canada), Ministry of Health letter (J1 Applicants), official Medical School transcript, and Diploma which bears an iginal notary seal (with the statement This is a true copy of the iginal document ) Visa Status Questionnaire Three (3) Letters of Recommendation One (1) Passpt-Style Photograph ** Items marked by an asterisk must be either an iginal document a notarized copy of an iginal document. Notarized copies must bear the following statement: "This is to certify that this is a copy, made in my presence, of an iginal document which bears no evidence of alteration." Any document which is in a language other than English, must be accompanied by a translated document which must be translated by an official translat and notarized. Thus, both the iginal language document and the translated document must be notarized.

3 BAYLOR COLLEGE OF MEDICINE ELECTROPHYSIOLOGY FELLOWSHIP PROGRAM BAYLOR ST. LUKE S MEDICAL CENTER/ TEXAS HEART INSTITUTE 2018 APPLICATION Mohammad Saeed, M.D. Telephone and Fax Inquiries to: Direct, Electrophysiology Program Bayl St. Luke s Medical Center Codinat, Cardiology Education 6720 Bertner Ave., MC Phone: (832) Houston, TX Fax: (832) Please provide a small passpt style photograph in this space. Cardiovascular Disease Fellowship training is a minimum of 3 years. Interventional Cardiology and Electrophysiology require a 4 th possibly 5 th year of training. APPLICATION DEADLINE IS January 15, 2016 This program is not a part of the National Resident Matching Program. Application f fellowship appointment in (specialty): Level of training applied f: Beginning: Month/Day/Year NAME: Last First Middle Present : Telephone: (Home) Telephone (Hospital School) Social Security Number: Permanent Home : Name and address of someone always able to contact you: Birthdate: Month, Day, Year Place of Birth Citizenship If non-citizen, date of entry into US If non citizen, type of visa currently held (Exchange Visit, Immigrant, etc.): Do you have any conditions which might impair your participation in the program? If so, please describe. EDUCATION: College Name From To Degree Medical School Name From To Degree Name From To Degree

4 Hospital From To Field Residency City and State Hospital From To Field And City and State Hospital From To Field Fellowship City and State Graduate College From To Degree(s) School Field(s) Practice Location From To Type Other clinical Location From To Experience Type College From To Faculty Department Rank Appointments College From To Department Rank U.S. Board certification Specialty Certified eligible (circle one) Date of certification Eligibility Specialty Certified eligible (circle one) Date of certification State Year Issued MEDICAL LICENSURE: State Year Issued

5 Indicate sces of completed exams (attach a photocopy of results) indicate date taken if results are not yet available. United States Medical Licensing Examination (USMLE): Step I ; Step II ; Step III National Board Exams (NBE): Part I ; Part II ; Part III FLEX Exam: Component I ; Component II ; Feign Medical Graduates Exam (FMGEMS) Sces: Basic Science ; Clinical Science Feign Medical Graduates Only: Attach a notarized photocopy of a valid Educational Commission f Feign Medical Graduates (ECFMG) certificate interim letter (Fm 135) current, non-restricted license to practice medicine from another state (USA Canada). PROFESSIONAL GOALS AND CAREER PLANS (omit if included in CV personal statement) RESEARCH EXPERIENCE: PUBLICATIONS: REFERENCES: Program Direct If applicable, please list publications on a separate sheet. Please request three (3) physicians professional superviss to send a letter of evaluation. One letter must be from the Cardiology Program Direct and two from physicians with whom you have wked during your residency. Please ask that your evaluats comment on academic and personal attributes such as judgment, industry, interpersonal relations, capacity to assume responsibility and professional ethics. Please have these recommendations sent directly to the address listed below. Other Recommenders I certify that to the best of my knowledge the above infmation is accurate and crect. Date: Signature: Please Letters of Recommendations To: Please All Other Crespondence To: Mohammad Saeed, M.D. Direct, Electrophysiology Program Codinat, Fellowship Program Bayl St. Luke s Medical Center / Texas Heart Institute Bayl St. Luke s Medical Center 6720 Bertner Ave., (MC 1-133) 6720 Bertner Ave., (MC 1-133) Houston, Texas Houston, Texas CardFell/Website/EPAppl2018

6 Bayl College of Medicine International Services Office One Bayl Plaza, Room 103H, MS: BCM410, Houston, Texas Tel: (713) / Fax: (713) VISA STATUS QUESTIONNAIRE FOR INTERNATIONAL MEDICAL GRADUATES Used solely f applicant as an international medical graduate at Bayl College of Medicine. Completing this fm does not guarantee sponsship. All international medical graduates must complete this visa status questionnaire. Please submit this visa status questionnaire, the applicant s application fm and curriculum vitae to the International Services Office (ISO). / / Last/Family Name (please print) First Middle PLEASE CHECK THE BOX THAT APPLIES TO YOU: U.S. Citizen U.S. Permanent Resident (immigrant green card holder). Please provide a copy of your alien registration card (green card). Pending Immigrant. Please provide a copy of your valid employment authization document (EAD card) Currently in the U.S. on the F-1 student visa and will be graduating from a U.S. medical school. Applied f OPT and will be using the 12-month optional practical training (OPT) to do the start residency. Please provide a copy of all your visa documents (I-94 card, I-20s, and passpt identification and visa stamp pages). Currently in the U.S. on the J-1 visa sponsed by ECFMG and need to apply f J-1 continuation of sponsship through ECFMG. Please provide a copy of all your visa documents (I-94 card, IAP-66/DS- 2019s, and passpt identification and visa stamp pages). Currently in the U.S. on the J-1 visa f the purpose of study, research teaching and need to apply f J- 1 sponsship through ECFMG. Please provide a copy of all your visa documents (I-94 card, IAP-66/DS- 2019s, and passpt identification and visa stamp page). Outside the United States and need to apply f visa sponsship None of the above applies. Please explain: I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT: Print Name Signature Date CardFell/Website/EPAppl2018

7 In accdance with State law, I hereby release and hold harmless from any liability loss, Bayl St. Luke's Medical Center, its officers, agents, and employees and members f acts perfmed in good faith and without malice in connection with evaluating my application, credentials, and qualifications, and hereby release from any liability any and all individuals and ganizations, to their authized representatives, concerning my professional competence, ethical conduct, character, and other qualifications f fellowship. Signature of applicant Date Printed typed name of applicant CardFell/Website/EPAppl2018

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