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1 Jefferson Health System Check program for which you are applying Name in full: Last First Middle Present Mailing Address: Telephone: Day Evening Social Security No.: Permanent Mailing Address: Pre-Medical College Attended with Degrees Conferred: Medical College Attended with Year of Graduation: Internship: Dates of Start and Completion Type Name and Address of Hospital: Residency: Dates of Start and Completion Type Name and Address of Hospital: Fellowship: Dates of Start and Completion Name and Address of Hospital: For all applicants: The application must be accompanied by (1) transcript of medical school record or Dean s letter from medical school; (2) USMLE I, II, III scores; (3) one letter of recommendation from Residency Program Director; (4) one letter of recommendation from Fellowship Program Director. Publications (if any): Research Experience: Medical License No.: State and Year: Signature Date of Application

2 FOR GRADUATES OF INTERNATIONAL MEDICAL SCHOOLS THE APPLICATION MUST BE ACCOMPANIED BY: (1) A COPY OF MEDICAL SCHOOL DIPLOMA (2) LETTER FROM INTERNSHIP HOSPITAL (3) LETTER FROM TWO SPONSORS (PREFERABLY INDIVIDUALS IN THE UNITED STATES) (4) A COPY OF STANDARD ECFMG CERTIFICATE ALL INTERNATIONAL MEDICAL GRADUATES ARE TO ANSWER THE FOLLOWING QUESTIONS: NATIONALITY: DATE OF ENTRANCE TO THE UNITED STATES: PLACE OF BIRTH (CITY): TYPE OF VISA VISA # EXPIRATION DATE PASSPORT# ISSUED BY (COUNTRY) EXPIRATION ECFMG CERTIFICATE# EXPIRATION DATE OF I-94 FORM (ARRIVAL-DEPARTURE RECORD) Signature Date of Application When completed please return to one of the following: Douglas B. Esberg, MD Program Director Clinical Cardiac Electrophysiology Fellowship Lankenau Medical Center Medical Office Building East 100 East Lancaster Avenue, Suite 558 Wynnewood, PA

3 CLINICAL CARDIAC ELECTROPHYSIOLOGY Requirements: Completed applications must contain a medical school transcript, curriculum vitae, personal statement, USMLE Report (Steps 1, 2 and 3), ABIM Board Score Report, and three letters of recommendation. One of the letters must be from the Program Director. Letters of recommendation should be directed to the Program Director, Dr. Douglas Esberg. Deadline for Receipt: Completed applications will be accepted through January 31, Selected candidates will be invited for an interview. Questions should be directed to: Rose Marie Wells, Program Coordinator Lankenau Heart Institute 558 Lankenau MOB East 100 East Lancaster Avenue Wynnewood, PA

4 The mission of Main Line Health is to provide a comprehensive range of safe, high-quality health services, complemented by related educational and research activities, that meet health care needs and improve the quality of life in the communities we serve. Founded in 1985, Main Line Health (MLH) is a not-for-profit health system serving portions of Philadelphia and its western suburbs. At its core are four of the region s respected acute care hospitals Lankenau Medical Center, Bryn Mawr Hospital, Paoli Hospital and Riddle Hospital as well as one of the nation s premier facilities for rehabilitative medicine, Bryn Mawr Rehab Hospital; Mirmont Treatment Center for drug and alcohol recovery; and HomeCare & Hospice, a home health service. Main Line Health also consists of Main Line HealthCare, one of the region s largest multi-specialty physician networks, and the Lankenau Institute for Medical Research, a non-profit biomedical research organization located on the campus of Lankenau Medical Center. Main Line Health is also comprised of four outpatient health centers located in Broomall, Collegeville, Exton and Newtown Square. Main Line Health Hospitals, with more than 10,000 employees and 2,000 physicians, are the recipients of numerous awards for quality care and service, including System Magnet designation, the nation s highest distinction for nursing excellence. Main Line Health is among the area s leaders in medicine, providing advanced patient-centered care, education and research to help our community stay healthy. Thomas Jefferson University Hospitals have major programs in a wide range of clinical specialties. Services are delivered at five primary locations Thomas Jefferson University Hospital (the main hospital facility, which was established in 1825) and Jefferson Hospital for Neuroscience, both in Center City Philadelphia; Jefferson's Methodist Hospital and Jefferson at the Navy Yard, both in South Philadelphia; and Jefferson at Voorhees in South Jersey. There are also various radiation therapy satellite locations throughout the region. Formerly a division of Thomas Jefferson University, the Hospital was separated from the University to become a founding member of the Jefferson Health System in The Hospital expanded its services to the community with the merger of Methodist Hospital as a division of Thomas Jefferson University Hospitals in Lankenau Medical Center, a member of Main Line Health, is recognized as a national leader in advancing new options to diagnose and treat illness, protect against disease and save lives. Located on a 93-acre suburban campus just outside of Philadelphia, Lankenau Medical Center is a 389-bed, notfor-profit teaching hospital that includes one of the nation s leading cardiovascular centers; the Lankenau Institute of Medical Research, one of the few freestanding hospital-associated research centers in the nation; and the Annenberg Conference Center for Medical Education. Lankenau offers state-of-the-art services from cancer care to maternity care. Lankenau is ranked as number six in Pennsylvania and number four in the Philadelphia metro area in U.S. News & World Report s Best Hospitals. Lankenau Medical Center is also ranked nationally for diabetes and endocrinology, and is high-performing in eight specialties: cardiology & heart surgery, diabetes & endocrinology, gastroenterology & GI surgery, geriatrics, neurology & neurosurgery, orthopedics, pulmonology and urology. Lankenau has achieved The Joint Commission s Gold Seal of Approval for stroke care and breast cancer care and is one of the nation s Top Performing Hospitals for heart attack, heart failure, pneumonia and surgical care. Lankenau has also been ranked for multiple years as one of the top 50 cardiovascular hospitals in the nation by Truven Health Analytics. Lankenau has earned Magnet designation for the third time for its superior nursing staff. Founded in 1927, the Lankenau Institute for Medical Research (LIMR) is an independent, nonprofit biomedical research center located in suburban Philadelphia on the campus of Lankenau Medical Center. Part of Main Line Health, LIMR is one of the few freestanding, hospital associated medical research centers in the nation. The faculty and staff at the Institute are dedicated to advancing an understanding of the causes of cancer, heart disease and diabetes. This information is used to help improve diagnosis and treatment of these diseases as well as find ways to prevent them. LIMR is also committed to extending the boundaries of human health and well-being through technology development and the training of the next generation of scientists and physicians. Lankenau Medical Center is located in Wynnewood, Pennsylvania, part of Philadelphia's Main Line suburbs, which are famous for their outstanding environment and quality of life. About fifteen minutes away by either car or public transportation, Center City Philadelphia offers attractions as varied as regional and national theater, the Pennsylvania ballet, the Philadelphia Orchestra, exciting professional and collegiate sports, a wide range of film and music outlets, the Mummers Parade, and hundreds of restaurants serving food ranging from local favorites, like cheese steaks, to nationally renowned French cuisine and other ethnic specialties. Philadelphia also features the Philadelphia Art Museum and the Franklin Institute, among the 26 museums within the city alone; the 8,700-acre Fairmount Park; Penn's Landing, the Morris Arboretum; and historic sites, including Independence Hall and the Liberty Bell. Attractions outside the city include the Brandywine Museum on the Wyeth family estate; and seven parks in the area offer swimming, hiking, riding, and fishing, among other activities. New York City and Baltimore, Maryland, are both near enough for day trips, and the Pocono Mountains and New Jersey, Delaware, and Maryland beaches all offer weekend alternatives. Nearby historical sites include Valley Forge National Park, the battleground at Gettysburg, and other reminders of the area's long history. Lankenau is located just outside the western city limits of Philadelphia in Wynnewood, Pennsylvania. Philadelphia is served by national train and bus transportation, and by national and international air transportation. Once in Philadelphia, you can get to Lankenau by car, taxi, train, or bus via the following directions: From Center City, Philadelphia BY TRAIN, from Philadelphia's 30th Street or Suburban Station, take SEPTA's R5 "Paoli Local" to either Overbrook or Wynnewood. From Overbrook, it is a fifteen-minute walk up City Ave. to Lancaster, then west along Lancaster to the Hospital From Wynnewood, it is possible to catch the 105 bus; ask a SEPTA official or look for the sign marking the stop in the parking tot across the street. BY SUBWAY AND BUS, take the Market- Frankford Elevated line to the 69th Street terminal, and transfer to the 105 bus to Lankenau. The SEPTA G bus, which serves major portions of the city, also stops at Lankenau.

5 From Center City, Philadelphia (continued) BY CAR, take Route 76 (the Schuylkill Expressway) west to City Avenue (Route 1). Exit onto City Avenue, turn right, at the bottom of the ramp, and travel south to the intersection of City and Lancaster Avenue (Route 30). Turn right on Lancaster to the first light. Turn left into the Lankenau drive. From the Airport A SEPTA train runs from the Philadelphia International Airport to 30th Street Station. By car, travel south from the airport on I-95 to the exit for Route 476 (the Blue Route). Travel north on the Blue Route to the Route 1 exit. Follow Route 1 north several miles to Route 30 (Lancaster Avenue). Turn left on Route 30 (west) to first traffic Light. Turn left into Lankenau drive. If driving to Philadelphia and Lankenau Medical Center, use the following directions: From the North Take I-95 to Philadelphia. Exit 95 onto Route West in Philadelphia. Exit Route 76 onto City Avenue, and turn right at the bottom of the ramp. Travel south on City Avenue (Route 1) to the intersection of Lancaster Avenue (Route 30). Turn right onto Lancaster Avenue to the first traffic light. Turn left into Lankenau drive. From the South Take I-95 to Philadelphia. Exit 95 onto Route 476 North (the Blue Route). Exit 476 at the Route 1 exit. Follow Route 1 North several miles to Route 30 (Lancaster Avenue). Turn left on Route 30 (west) to first traffic light. Turn left into Lankenau drive. From the East/West Take the Pennsylvania Turnpike to Valley Forge. Exit onto Route 76 East (Schuylkill Expressway). Follow to Route 1 exit (City Avenue). Exit south onto Route 1; follow to Route 30 (Lancaster Avenue). Turn right (west) onto Route 30 to first traffic light. Turn left into Lankenau drive. From the Western Suburbs Take Route 30 (Lancaster Avenue) to the Lankenau entrance, which is Located just west of City Avenue. From the Southern Suburbs Take Route 1 north to Route 30. Go west on Route 30 approximately 1/4 mile to the Lankenau entrance. Accommodations are offered as suggestions only. Holiday Inn City Ave &, Presidential Blvd. Philadelphia, PA / Approximately three miles north of Lankenau Medical Center on City Avenue (Route 1, near junction of Schuylkill Expressway). Contact the Reservations Manager and request the "Lankenau Patient Relations Rate" at the time you make your reservation. #65 bus to 63rd and Lancaster Avenue, transfer to the "G" bus to come to Lankenau Medical Center. Hilton Philadelphia City Avenue 4200 City Avenue Philadelphia, PA / Approximately three miles north of Lankenau Medical Center on City Avenue (Route 1, near junction of Schuylkill Expressway). For reservations, request the Lankenau Preferred Rate. Radnor Hotel Lancaster Avenue St. Davids, PA / Approximately five miles west of Lankenau Medical Center on Lancaster Avenue (Route 30). Bus service available until 6:30 p.m. Ask for the Corporate Rate. Wayne Hotel 139 East Lancaster Ave., Wayne, PA / Victorian hotel approximately seven miles west of Lankenau Medical Center on Lancaster Avenue (Route 30). Ask for the Corporate Rate.

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