First Name
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Last Name
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Gender
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Male Female Other Gender Identification No Answer
AAMC ID Number
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If none, type "none"
USMLE ID Number
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If none, type "none"
National Provider Identifier Number (NPI)
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If none, type "none"
Street Address
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands
Country
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Email Address
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Preferred Phone
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Is your permanent address the same as your current contact address?
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Yes
No
Street Address
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming District of Columbia Puerto Rico Guam American Samoa U.S. Virgin Islands Northern Mariana Islands
Country
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Birth Date
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Today M-D-Y
Place of Birth
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City, Country
Self-Identification
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American Indian/Alaskan Native Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White/Caucasian Other Choose Not To Answer
Are you certified by ECFMG?
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Yes
No
ECFMG Number
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List languages in which you are fluent other than English
List your hobbies and interests
Are you authorized to work in the U.S.
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Yes
No
Are you a citizen of the United States?
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Yes
No
Country of Citizenship
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Current Visa Type, if applicable
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If none, type "none"
Will you require visa sponsorship during your fellowship training?
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Yes
No
Pass
Fail
Today M-D-Y
USMLE Step 2 (Clinical Knowledge)
Pass
Fail
Today M-D-Y
USMLE Step 2 (Clinical Skills)
Pass
Fail
Today M-D-Y
Pass
Fail
Today M-D-Y
Osteopathic - COMLEX Part 1
pass
fail
Today M-D-Y
Osteopathic - COMLEX Part 2 CE (Cognitive Examination)
pass
fail
Today M-D-Y
Osteopathic - COMLEX Part 2 PE (Performance Evaluation)
pass
fail
Today M-D-Y
Osteopathic - COMLEX Part 3
pass
fail
Today M-D-Y
Are you ACLS certified in the United States?
* must provide value
Yes
No
ACLS Expiration Date
* must provide value
Today M-D-Y
Are you PALS certified in the United States?
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Yes
No
PALS Expiration Date
* must provide value
Today M-D-Y
Are you Board Certified?
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Yes
No
Which Board?
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Were you ever named in a malpractice suit?
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Yes
No
Do you have a state medical license?
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Yes
No
State
* must provide value
License Number
* must provide value
Expiration Date
* must provide value
Today M-D-Y
DEA Registration
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Yes
No
DEA Registration Number
* must provide value
Institution Name
* must provide value
Institution Country
* must provide value
Education Start Month
* must provide value
Education Start Year
* must provide value
Education End Month
* must provide value
Education End Year
* must provide value
Degree Earned
* must provide value
M.D. M.D./Ph.D. D.O. M.B.B.S. M.B.B.Ch. M.B.Ch.B. M.Med. B.Med. M.Surg. M.C. Other
If Other, Please Specify Degree
* must provide value
Degree Month
* must provide value
Degree Year
* must provide value
Was your medical education or training extended or interrupted?
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Yes
No
If yes, please provide an explanation:
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Please Specify Awards and Honors
Please Specify Professional Memberships
Institution Name
* must provide value
Institution Country
* must provide value
Education Start Month
* must provide value
Education Start Year
* must provide value
Education End Month
* must provide value
Education End Year
* must provide value
Degree Earned
* must provide value
Degree Month
* must provide value
Degree Year
* must provide value
Program of Study/Specialization:
* must provide value
Program of Study/Specialization:
Type of Training
* must provide value
Specialty
* must provide value
Institution Name
* must provide value
Institution Country
* must provide value
Name of Program Director
* must provide value
Training Start Month
* must provide value
Training Start Year
* must provide value
Training End Month (or anticipated)
* must provide value
Training End Year (or anticipated)
* must provide value
Add More Medical Training
* must provide value
Yes
No
Type of Training
* must provide value
Specialty
* must provide value
Institution Name
* must provide value
Institution Country
* must provide value
Name of Program Director:
* must provide value
Training Start Month
* must provide value
Training Start Year
* must provide value
Training End Month (or anticipated)
* must provide value
Training End Year (or anticipated)
* must provide value
Add More Medical Training?
* must provide value
Yes
No
Type of Training
* must provide value
Specialty
* must provide value
Institution Name
* must provide value
Institution Country
* must provide value
Name of Program Director
* must provide value
Training Start Month
* must provide value
Training Start Year
* must provide value
Training End Month (or anticipated)
* must provide value
Training End Year (or anticipated)
* must provide value
You can enter up to three
Name of Organization/Hospital/Practice:
* must provide value
City, Country
* must provide value
Experience Type
* must provide value
Position
* must provide value
Start Date
* must provide value
Today M-D-Y
End Date (or anticipated)
* must provide value
Today M-D-Y
Role and Responsibilities
* must provide value
Add more Clinical Work Experience?
* must provide value
Yes
No
Name of Organization/Hospital/Practice
* must provide value
City, Country
* must provide value
Experience Type
* must provide value
Position
* must provide value
Start Date
* must provide value
Today M-D-Y
End Date (or anticipated)
* must provide value
Today M-D-Y
Role and Responsibilities
* must provide value
Add more Clinical Work Experience?
* must provide value
Yes
No
Name of Organization/Hospital/Practice
* must provide value
City, Country
* must provide value
Experience Type
* must provide value
Position
* must provide value
Start Date
* must provide value
Today M-D-Y
End Date (or anticipated)
* must provide value
Today M-D-Y
Role and Responsibilities
* must provide value
Have you ever been reported to the National Practitioner Data Bank, Healthcare Integrity and/or Protection Data Bank?
* must provide value
Yes
No
Has your employment, medical staff appointment, panel participation, affiliation or clinical privileges ever been voluntarily or involuntarily suspended, diminished,
revoked, refused or limited in any hospital, health care facility or managed care
organization, IPA or PPO including to avoid disciplinary action for reasons related to
professional competence or conduct?
* must provide value
Yes
No
Has your license to practice your profession in any jurisdiction every been limited, restricted, suspended, revoked, denied or subject to probationary conditions?
* must provide value
Yes
No
Have you ever voluntarily or involuntarily relinquished your license to practice your profession in any state?
* must provide value
Yes
No
Have you ever been suspended, sanctioned or otherwise restricted from participating in any private, federal or state health insurance program (including Medicare, Medicaid or a managed care organization)?
* must provide value
Yes
No
Has your narcotics registration certificate ever been voluntarily or involuntarily limited, restricted, denied renewal, suspended or revoked?
* must provide value
Yes
No
Have you ever been denied membership, membership renewal or been subject to any professional review, censure or reprimand in any medical organization or professional society - local, state or national?
* must provide value
Yes
No
Have you ever been subject to disciplinary action by a state agency or professional body (i.e., Medical Society, IPRO, OPMC)?
* must provide value
Yes
No
Please elaborate on your answer
* must provide value
Has your specialty board certification or qualification ever been voluntarily or involuntarily denied, revoked, relinquished, not renewed, suspended or reduced?
* must provide value
Yes
No
Do you have any pending misconduct charges against you in this state or any other state?
* must provide value
Yes
No
Have you ever been convicted of a misdemeanor or felony in any jurisdiction? ..
* must provide value
Yes
No
Are you presently or have you ever been subject to any suspension, revocation, discontinuance, limitation, restriction, monitoring or probationary proceedings?
* must provide value
Yes
No
Have you ever been cited for violation of patient rights as set forth by the Federal Law and/or NYS Department of Health or any other state department of health?
* must provide value
Yes
No
Has your professional liability insurance coverage ever been denied or not renewed by action of any insurance company?
* must provide value
Yes
No
Has your professional liability insurance coverage ever been surcharged, suspended or terminated by action of any insurance company?
* must provide value
Yes
No
Has your present professional liability insurance carrier excluded any specific procedures from your coverage?
* must provide value
Yes
No
Have any professional liability suits been filed against you which are currently pending in this or any other state?
* must provide value
Yes
No
Have any professional liability judgments and/or settlements ever been made against you or on your behalf?
* must provide value
Yes
No
Attestation: I hereby waive any confidentiality provision concerning the information provided in this application, pursuant to New York State Public Health Law section 2805-k.
If this application leads to my employment, I understand that false or misleading information in my application or interview may result in my release.
I certify that my answers are true and complete to the best of my knowledge.
* must provide value
Yes
No
I agree to update this form while it is being processed, should there be any change in the information provided.
* must provide value
Yes
No
I understand that any misrepresentation, misstatement or omission on this form could result in revocation of any privileges/employment granted and subject to reporting according to NYS regulations.
* must provide value
Yes
No
I am not currently using any illegal drug, nor have I during the past two years.
* must provide value
True
False
I authorize release of reference information by all past and present employers/educational institutions
* must provide value
Yes
No
I acknowledge by my signature below that a drug test will be a condition of employment.
Signature
* must provide value
Applicant Name(Printed)
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Date of Completion
* must provide value
Today M-D-Y
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