Department of Medicine Hospice & Palliative Medicine Fellowship Application

Transcription

1 Instructions Application for Admission Fellowship Program The New York Hospital Queens Hospice and Palliative Medicine Fellowship Program welcome applicants from Internal Medicine and Family Medicine. Applications are accepted throughout the year, and interviews are conducted by appointment only. The applicant will be notified if an interview is desired. Preparation of Application A complete application packet includes: Application form Personal statement Curriculum Vitae (CV) Copy of USMLE scores Copy of Medical School Diploma Three Letters of Recommendation Copy of Transcript of Medical School Records Applicants who have recently completed residency training should request three letters of recommendation from faculty members in their specialty area who are familiar with their work. One of the letters must be from the Residency/Fellowship Program Director. Letters should be sent by either fax to (718) or preferably as scanned pdfs directly to both addresses listed below. Return of Application Please completed application to: Director, New York Hospital Queens Hospice and Palliative Medicine Fellowship Program: Fernando Kawai, MD fek9007@nyp.org NYHQ - HPM Fellowship Coordinator: Sandra Cardenas-Arroyave sac9026@nyp.org

2 INSTRUCTIONS TO APPLICANT: Answer all questions completely. If more space is necessary to answer all questions, attach an additional sheet. PERSONAL DATA Name: Last:: First: Middle: Current Employer/Position Mailing Address: Street, City, State and Zip Code: Address: Home Phone: Work Phone: Cell Phone: CITIZENSHIP STATUS U.S. Citizen: J-1: EAD: Permanent Resident: HIGHER EDUCATION Please list all schools attended. Please fill in information in this form. DO NOT refer to CV Institution City, State, Country Postgraduate Dates Attended From: Mo Yr. To: Mo Yr. Degree Conferred Type Date Medical School Undergraduate GRADUATE MEDICAL EDUCATION Include current and previous graduate medical education. Please fill in information in this form. DO NOT refer to CV Internship Type From Mo./Yr. To Mo./Yr. Name and contact information of Program Director

3 Residency Type Fellowship Type LICENSURE Please fill in information in this form. DO NOT refer to CV Licensure (temporary permit; full/complete) Current visa status: Entry date Expiration date State Number Date granted Type Expiration date Type of visa SIGNIFICANT NON-MEDICAL EXPERIENCE Please fill in information in this form. DO NOT refer to CV Type Location Dates RESEARCH EXPERIENCE Indicate UG/ Grad /Med Student. Please fill in information in this form. DO NOT refer to CV Type Location Dates

4 PERSONAL STATEMENT Attach a statement of purpose and your future career plans related to. Do not exceed 1500 words. CURRICULUM VITAE Please attach a current curriculum vitae. FUTURE PROFESSIONAL GOALS (where do you see yourself 5 and 10 years from now) LETTERS OF RECOMMENDATION REQUESTED: Include full name and address of institutions. One letter MUST be from the Program Director of your residency program. Letters should be ed in pdf format directly from the reference to: Sandra Cardenas-Arroyave, Fellowship Coordinator, sac9026@nyp.org Are you now or have you ever been excluded, debarred or suspended from participation in the Medicare or Medicaid programs or any other federal procurement program? No Yes Have you been convicted of or have you pled guilty to any crime or municipal ordinance violation, including misdemeanors and traffic violations other than a parking ticket? No Yes If yes, complete below: (Conviction will not necessarily disqualify an applicant from employment; however, omission of convictions may be considered falsification of the application which could result in disqualification.) Date Charge City & State Fine or Disposition

5 SUPPLEMENTAL INFORMATION (optional) Please note that NYHQ is committed to increasing representation of women and members of minority groups in its residency and fellowship training programs, and particularly encourages applications from such individuals. The Department of General Internal Medicine fully supports this policy. You are invited to identify, from the list below, your racial/ethnic background. Your choice to provide or not to provide this information will in no way affect your application. Race/Ethnicity: American Indian or Alaska Native Black or African American Hispanic/Latino White or Caucasian Native Hawaiian / Other Pacific Islander, Specify Asian Asian Indian Chinese Filipino Japanese Korean Thai Vietnamese Hmong Southeast Asian-Cambodian OR Specify Other The information I have given in this application is current and complete to the best of my knowledge. Signature Date