ofAmericanPathologistsResidentsForum StandardizedApplicationforPathologyFellowships ApplicantName Lastname First Middle FellowshipType Thisapplicationisbeingmadeforafellowshipin(pleasecheckone): Bloodbanking/Transfusionmedicine Breastpathology Chemistry athology athology Diagnosticimmunology Forensicpathology Gastrointestinalpathology Genitourinarypathology Gynecologicpathology athology Medicalmicrobiology Molecularicpathology Neuropathology Pathologyinformatics Pediatricpathology Pulmonary/Mediastinalpathology Renalpathology Softtissue/Bonepathology Surgical/Oncologicpathology Other,pleasespecify: Trainingperiodforwhichapplying: Startdate PersonalData Othernamesused:PresentAddress Street PermanentAddress Street Telephone Home Work E-mail: Citizenship Countryofcitizenship CityCity Mobile Visastatus Pleaseaffixarecentpassportsizedphotohere. Ifsubmittingelectronically,includearecentpassport-stylephotoin.JPGformatwiththe application. Finishdate State ZIP/Postalcode State ZIP/Postalcode Fax ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314 Education (Mo/Yr) to (Mo/Yr) to (Mo/Yr) to (Mo/Yr) to (Mo/Yr) to (Mo/Yr) to (Mo/Yr)
(Mo/Yr)(Mo/Yr)(Mo/Yr)(Mo/Yr)(Mo/Yr) (UndergraduateSchool)(GraduateSchool,ifapplicable)(MedicalSchool)(Residency)(OtherGME,ifapplicable)(OtherGME,ifapplicable) (Major)(Major)(Country) (Degree)(Degree)(Degree)(AP,CP,AP/CP,other)AreaoftrainingAreaoftraining OtherExperience Inchronologicalorder,listothereducationalexperiences,jobs,militaryserviceortrainingthatisnotountedforabove. (Mo/Yr) (Mo/Yr) to (Mo/Yr) (Mo/Yr) to (Mo/Yr) (Mo/Yr) to NationalBoards Pleaseindicatenationalboardexaminationdatesandresultsreceived. USMLEStep1 Datepassed Score(optional) USMLEStep2 CK-Datepassed Score(optional) CS-Datepassed Score(optional) USMLEStep3 Datepassed Score(optional) Forgraduatesofinternationalmedicalschools,areyouECFMG-certified?
ECFMGCertificateNumber COMLEXLevel1 Datepassed Score(optional) COMLEXLevel2 Datepassed Yes NoIfyes,providecertificatenumberanddategranted. DateECFMGCertificateGranted MM-YYYY Score(optional) COMLEXLevel3 Datepassed Score(optional) MedicalLicensure Pleaselistanystatesinwhichyouholdalicensetopracticemedicine.Pleaseprovidealicensenumber.Ifanapplicationis pendinginastate,pleasewrite“pending.” (State) (DateIssued) (MedicalLicenseNumber) (Active?
) (State#2) (DateIssued) (MedicalLicenseNumber) Yes No (Active?
) Yes No Haveyoueverbeenreprimanded,orhadyourlicensesuspendedorrevokedinanyofthesestates?
Yes(Ifso,pleaseexplaininanattachedsheet.)No Haveyoueverbeennamedin(and/orhadajudgmentagainstyou)inamedicalmalpracticelegalsuit?
Yes(Ifso,pleaseexplaininanattachedsheet.)No ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314 Board
CertificationPleaseindicateanyareasofboardcertification. Board AreaofCertification DateofCertification Honors,Awards,Publications,Presentations,Memberships,Leadership/ResearchExperiencePleaselistonattachedapplicationformsorincludethisinformationinyourCV. Lettersofmendationand/orReferences Pleaselisttheindividualswhowillwriteyourlettersofmendation.Atleastthreearerequired. Reference#
1 Name Title Institution Address City State ZIP/PostalCode Telephone Email Reference#
2 Name InstitutionAddressTelephone Title City State ZIP/PostalCode Email Reference#
3 NameInstitutionAddressTelephone Title City State ZIP/PostalCode Email Reference#4(optional) NameInstitutionAddressTelephone Title City State ZIP/PostalCode Email Signature(mayomitifsubmittingelectronically) Iherebycertifythatalloftheinformationonthisapplicationisurate,plete,andcurrenttothebestofmyknowledge,andthatthisapplicationisbeingmadeforseriousconsiderationoftraininginthePathologyFellowshipindicated.Iunderstandthateptingmorethanonefellowshippositionconstitutesaviolationofprofessionalethicsandmayresultintheforfeitureofallpositions. Signature Date ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314 Honors
andAwards(ifexplicitlylistedonCV,includehighlightsherewithreferencetolocationonCV) ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314 Publications
andPresentations(ifexplicitlylistedonCV,includehighlightsherewithreferencetolocationonCV) ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314 Memberships
andLeadership/ResearchExperience(ifexplicitlylistedonCV,includehighlightsherewithreferencetolocationonCV) ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314 Residents
ForumSuggestedTimelineforApplication Beginningone-and-a-halfyearsbeforetheproposedstartofafellowshipforwhichtheapplicationisbeingmade,thefollowingtimelineismended: December1DeadlineforreceiptofpletedResidentsForumStandardizedApplicationandallsupportingdocumentation(lettersofmendation,etc.) March1 Deadlineforprogramtomakeofferstoapplicants ApplicationPacketCheck-listCompletedStandardizedFellowshipApplicationFormwithSignatureUpdatedCurriculumVitae(CV)Includedcoverletterand/orpersonalstatementCheckedwiththefellowshipdirectororcoordinatorwhetherthereareotheritemsthatshouldbeincludedIncludedphoto ©2013CollegeofAmericanPathologists.Allrightsreserved./apps/docs/pathology_residents/residents_forum_standardized_fellowship_application.doc 0429201314