Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL
Social Security Number
DOB
Year applying for

 US Citizen?

Yes No

Name of Person to contact in case of emergency with contact information:

Choose one of the following:

I certify that I am in good health and have no physical or mental limitations. I do have a chronic illness, physical disability and/or mental limitation to my health, which may include alcohol or drug use, but believe this does not significantly impair my ability to render quality patient care.

Enter your Medical School, City, State, Country and Dates attended in the space provided below.

If you are a graduate or will graduate from an international medical school, please answer the following questions:

Have you passed the USMLE Step I?

Yes No                  Score 

Have you passed the USMLE Step II?

Yes No                  Score 

Have you passed the USMLE Step III?

Yes No                  Score 

Enter your ECFMG Certificate Number in the space provided below.

Have you passed the FLEX Exam?

Yes No

Enter in the space provided below any other examination which qualifies you to apply for ECFMG certification?

Enter your Undergraduate Education in the space provided below. (included name, city, state, country and dates attended)

Enter your ACGME Accredited first year Residency (Internship) information in the space provided below.

Enter other Clinical Experience in the space provided below.

Enter your Graduate Work completed in the space provided below.

List publications and/or research work in which you may have participated in the space provided below.

Enter your Professional Practice in the space provided below. (include name, city, state, country and dates)

Enter your Medical Licensure (s) in the space provided below. (include state, license number and expiration date)

Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked?

Yes No          If yes, please explain here

Has you authorization to prescribe narcotics ever been rescinded?

Yes No          If yes, please explain here

Has any medical institution ever suspended, diminished, revoked or failed to renew your privileges?

Yes No          If yes, please explain here

Have you ever been denied membership or renewal, or been subject to disciplinary proceedings in any medical organizations?

Yes No          If yes, please explain here

Have you had any malpractice judgments against you within the past five years?

Yes No          If yes, please explain here

Have you ever been convicted of a felony?

Yes No         If yes, please explain here

Do you agree that if you accept an appointment with George Washington University Medical Center, you will not resign for a similar position at another institution?

Yes No

 

Statement of Applicant

All information submitted by me in this application is true to the best of my knowledge and belief,  I fully understand that any misstatements in or omissions from this application may cause for denial of appointment or cause for summary dismissal from the Fellowship Program.

 

 

Type Here

  

Electronic Signature

 

Insert CV (cut and paste)

 

 

 

 

UNIVERSITY POLICY ON DRUG TESTING

The Board of Trustees of the George Washington University are committed to making the University Hospital a drug-free environment. Within one week of beginning training, all housestaff will be tested and any house officer who is positive will be required to have counseling and/or monitoring and/or referral to the Medical Society of the District of Columbia.

The George Washington University does not unlawfully discriminate against any person on the basis of race, color, religion, sex, national origin, age, handicap, veteran status or sexual orientation. This policy covers all programs, services, policies and procedures of the University, including admission to education programs and employment. The University is subject to the District of Columbia-Human Rights Law.

Inquires concerning application of this policy and federal laws and regulations regarding discrimination in education or employment programs and activities may be addressed to Susan B. Kaplan, Assistant Treasure for Legal Matters. The George Washington University, Washington, DC 20052, (202) 994-6503, or to the Assistant Secretary for Civil Rights of the U.S. Department of Education. Disabled individuals who need special information should call the Office of Disabled Student Services (202) 994-8250 (TTD/voice).