Application Form Training Medical

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					       APPLICATION FOR A FOREIGN PHYSICIAN OR HEALTH CARE
                          PROFESSIONAL
PART 1
To be completed by the physician and should be forwarded with: 1) FULL RESUME OF EDUCATION AND
EMPLOYMENT 2) AN ESSAY OR LETTER (ABOUT 500 WORDS) DESCRIBING THE APPLICANT’S CAREER
GOALS AND REASONS FOR APPLYING TO THE INTERNSHIP. 3) THREE (3) LETTERS OF REFERENCE. 4)
NOTARIZED ENGLISH TRANSLATION OF DIPLOMA AND GRADES (OFFICIAL TRANSCRIPTS). 5) EIGHT (8)
PICTURES (passport size – smile, please!)
Position:       _____ International Scholar            _____ Research Associate

PERSONAL DATA:

Name _____________________________________________________________________________________
                  Family                                                  First

Address     __________________________________________________________________________________
                  Home                        Street                               Apartment
            __________________________________________________________________________________
                  City                                   country                   postal code

Telephone _________________________________________________________________________________
                           home                                           work

E-mail address     _______________________________                        Fax     _________________________________

Date of birth      _______________________________                        Sex:     _____ Male    ______ Female
                           month/day/year

City and country of birth:     ____________________________________________________________________

Citizenship:       _____________________________________________________________________________

Good health:       _____ Yes         _____ No If no, please specify           ____________________________________

Marital status: Single             Married               Divorced         Number of children:         _______

Current Position: from        _________________                    to      __________________

 __________________________________________________________________________________________
                                      Title                                  department

 __________________________________________________________________________________________
                                                            Institution

 __________________________________________________________________________________________
                                                           City/country


EDUCATION:
Advanced degree          __________________________________________________________________________

School/university        __________________________________________________________________________

Dates attended           __________________________________________________________________________
City/country            __________________________________________________________________________

Where and when did you learn English?

How often do you converse in English? __________________________________________________________

Assess your English skills:

Reading:           _____ fluent    _____ good       _____ average     ____ poor

Writing:           _____ fluent    _____ good       _____ average     ____ poor

Speaking:          _____ fluent    _____ good       _____ average     ____ poor

Comprehension: ____ fluent         _____ good       _____ average     ____ poor

ADDITIONAL INFORMATION

Are you certified by Foreign Medical Graduate Examination in Medical Sciences (FMGEMS)?

           ______ yes     ______ no

What other medical centers will you be visiting?        ________________________________________________

 __________________________________________________________________________________________

What are your personal objectives for your proposed visit?        ________________________________________

 __________________________________________________________________________________________

 __________________________________________________________________________________________

Desired time for this visit:   ____ month _____ year        Desired length of visit:   _____ weeks/months

List the departments you would like to visit:       ___________________________________________________

 __________________________________________________________________________________________


What are your areas of expertise and/or special interest?       __________________________________________

 __________________________________________________________________________________________

What are your current responsibilities and/or activities in your institution?

 __________________________________________________________________________________________

In what ways would you be able to participate in teaching activities?        ________________________________

 __________________________________________________________________________________________

List topics which you would be prepared to discuss or present:        _____________________________________

 __________________________________________________________________________________________
 __________________________________________________________________________________________

Signature    _______________________________             Date      ________________________
       APPLICATION FOR A FOREIGN PHYSICIAN OR HEALTH CARE
                          PROFESSIONAL

PART 2
To be completed by the Dean, Chairman, or other senior authorized representative of the institution sponsoring
the visit and should be forwarded with: 1) A SEPARATE LETTER FROM THE INSTITUTIONAL
REPRESENTATIVE, ON OFFICIAL STATIONARY. 2) INFORMATION ABOUT THE SPONSORING
INSTITUTION, E.G., BROCHURE, ANNUAL REPORT, NUMBER OF HOSPITAL BEDS, ETC.

Name of candidate        _______________________________________________________________________

Title of candidate       _______________________________________________________________________

Name of sponsoring institution        _____________________________________________________________

 __________________________________________________________________________________________

Address of institution   _______________________________________________________________________

Telephone        _________________________                Fax    ________________________________________


What are the objectives of your institution in sponsoring this candidate?        ____________________________

 __________________________________________________________________________________________

In what way will this appointment be of benefit to your institution?        ________________________________

 __________________________________________________________________________________________

Will the candidate be visiting any other medical facilities in the USA?

To what extent is the candidate expected to teach in your institution?

How do you assess the candidate's English skills?     ________________________________________________

In what ways will your institution support the candidate for this visit? (Check all that apply)
 ____________ Air fare           _________ Salary continuance ________________ Lodging expenses


Name and title of person to contact in sponsoring institution          _____________________________________

Telephone        _______________________________                Fax ____________________________________

E-mail address       ____________________________________________________________________________

Name of Dean, Chairman, or authorized representative _

Signature        _______________________________                          Date       ________________________

				
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