Desired Start Date:
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First Name:
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Last Name:
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Email address:
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AAMC Number:
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Date of Birth:
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Place of Birth:
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Are you a U.S. Citizen or National, legal permanent resident (green card holder), refugee, or asylee?
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Native Born
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Native Born
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U.S. Social Security Number:
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Are you authorized to work in the United States without restrictions?
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U.S. Social Security Number:
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Will you require visa sponsorship?
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Thank you for your interest in our
Vascular Medicine Fellowship . At this time, we are not accepting J-1 or H-1B visa holders. However, we are actively exploring opportunities to include J-1 visa applicants in the near future, as we value the diverse perspectives they bring to our programs.
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J-1 Exchange Visitors
H-1B
J-1 Exchange Visitors
H-1B
Self Identification:
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Other
Prefer not to disclose
Male
Female
Other
Prefer not to disclose
Self Identification (please choose all that apply):
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American Indian or Alaskan Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment
Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American: a person having origins in any of the black racial groups of Africa
Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race
Native Hawaiian or Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Other
Prefer not to disclose
American Indian or Alaskan Native: a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment
Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
Black or African American: a person having origins in any of the black racial groups of Africa
Hispanic or Latino: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race
Native Hawaiian or Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
White: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Other
Prefer not to disclose
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Graduation Date:
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Today M-D-Y
Degree(s):
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Graduation Date:
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Degree(s):
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Institution:
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Graduation Date:
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Today M-D-Y
Degree(s):
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Medical School:
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Are you an International Medical Graduate?
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Yes
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Are you ECFMG Certified?
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Country:
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Graduation Date:
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Today M-D-Y
Degree(s):
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Was your medical education interrupted?
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No
If yes, please explain.
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Today M-D-Y
Today M-D-Y
Have you completed any other internships?
Yes
No
Today M-D-Y
Today M-D-Y
Residency Institution:
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Specialty Area:
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City:
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State:
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Date Residency Began:
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Today M-D-Y
Date Residency Ended:
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Today M-D-Y
Residency Graduation Date:
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Today M-D-Y
Have you completed any other Residency Programs prior to the one above?
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Yes
No
Residency Institution:
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Specialty Area:
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City:
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State:
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Date Residency Training Began:
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Today M-D-Y
Date Residency Training Ended:
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Today M-D-Y
Have you completed a Fellowship Program?
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Yes
No
Fellowship Institution:
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Specialty Area
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City:
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State:
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Date Fellowship Began:
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Today M-D-Y
Date Fellowship Ended:
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Today M-D-Y
Have you completed any other Post Graduate Training?
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Yes
No
Institution:
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Specialty Area:
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City:
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State:
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Date Other Post Graduate Training Began:
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Today M-D-Y
Date Other Post Graduate Training Ended:
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Today M-D-Y
Do you currently have any military service commitment?
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If yes, please explain.
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Do you hold an active medical license?
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State:
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Medical License Number:
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Date License Issued:
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Today M-D-Y
Date License Expires:
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Today M-D-Y
Do you hold any active medical license in another state?
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No
State:
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Date License Issued:
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Today M-D-Y
Date License Expires:
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Today M-D-Y
Are you Board Certified?
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Yes
No
Specialty Area
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Has your medical license ever been suspended/revoked/voluntarily terminated?
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Yes
No
If yes, please explain.
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Have you been named in a malpractice case?
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Yes
No
If yes, please explain.
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Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?
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Yes
No
If yes, please explain.
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Are you able to carry out the responsibilities of a resident or fellow in the specialties and at the specific training programs to which you are applying, including the functional requirements, cognitive requirements, interpersonal and communication requirements, and attendance requirements with or without reasonable accommodations?
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Yes
No
If no, please explain.
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Have you ever been convicted of a misdemeanor?
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Yes
No
If yes, please explain.
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Have you been convicted of a felony?
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Yes
No
If yes, please explain.
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Name:
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Institution:
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Position:
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Is this your current or most recent Program Director?
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Please note: it is a requirement that one of the letters of recommendation must come from the current or most recent Program Director.
Name:
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Institution:
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Position:
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Name:
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Institution:
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Position:
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Personal Statement:
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USMLE (include STEP 1, STEP 2, STEP 3) / COMLEX Report (include COMLEX 1, 2, 3):
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Medical School Diploma:
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Medical School Transcripts:
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Photo:
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ECFMG certificate:
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I acknowledge the above answers and all information otherwise given by me as true, complete and not misleading in any way.
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I agree
Date Submitted
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INTERNAL USE ONLY: Mark done when complete.
This is complete
This form has not been completed by applicant
In-process
This is complete
This form has not been completed by applicant
In-process
Would you like to send this email to the sender? (You can customize this email in the blank space below)______ Dear ______ ______ , Thank you for your interest in the [fel_prog]. According to our records, your application is incomplete. If you are still interested in applying, please complete the application form at your earliest convenience. Sincerely, UT Southwestern Medical Center Department of Internal Medicine/Endocrinology Lilibeth.Goode@UTSouthwestern.edu
Yes, please
No thank you, I will email them separately
Yes, please
No thank you, I will email them separately
INTERNAL USE ONLY: Is the applicant missing letters of recommendation or official transcripts?
Yes
No
Would you like to send this email to the sender? (You can customize this email in the blank space below)______
Dear Dr. ______ ______ ,
Thank you for your interest in the [fel_prog] training program. According to our records, we have not received the following documents:
We would love to review your application if you are still interested in the position. If you would like to be considered for an interview, please have your missing documents sent via email or mailed to Endocrinology Education:
UT Southwestern Medical Center
Division of Vascular Medicine
5323 Harry Hines Blvd
Dallas, TX 75390
Best regards,
Vascular Medicine Fellowship Program
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No thank you, I will email them separately
Yes, please
No thank you, I will email them separately
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Indicate what documents are missing.
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