Desired Start Date:
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Today M-D-Y
Residency/Fellowship Program (select one):
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Emergency Medicine residency Clinical Ultrasound fellowship Emergency Medical Services Emergency Medicine & Disaster Global Health fellowship Medical Education in Emergency Medicine fellowship Medical Toxicology fellowship Simulation Based Medical Education fellowship
First Name:
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Last Name:
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Email address:
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NRMP Number (if applicable):
AAMC Number:
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Date of Birth:
* must provide value
Today M-D-Y
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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Yes
No
Native Born
Naturalized US
Permanent Resident (green card holder)
Refugee
Asylee
U.S. Social Security Number:
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Are you authorized to work in the United States without restrictions?
* must provide value
Yes
No
U.S. Social Security Number:
* must provide value
Will you require visa sponsorship?
* must provide value
Yes
No
Please note: UT Southwestern's Department of Emergency Medicine only accepts permanent residents or J-1 ECFMG certified visas. We do not routinely offer H1-B visas or any other type of visa.
Please specify which type of visa you require:
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J-1 Exchange Visitor
F-1 Student
H-1B Specialty Occupation Worker
TN (Treaty NAFTA) visa (Canadian or Mexican citizen only)
Self Identification:
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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
Address:
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City:
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State:
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Country:
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Zip or Country Code:
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Cell Phone:
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Institution:
* must provide value
City:
* must provide value
State:
* must provide value
Country:
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Graduation Date:
* must provide value
Today M-D-Y
Degree(s):
* must provide value
Are there any additional institutions that you attended?
* must provide value
Yes
No
Institution:
* must provide value
City:
* must provide value
State:
* must provide value
Country:
* must provide value
Graduation Date:
* must provide value
Today M-D-Y
Degree(s):
* must provide value
Are there any additional institutions that you attended?
* must provide value
Yes
No
Institution:
* must provide value
City:
* must provide value
State:
* must provide value
Country:
* must provide value
Graduation Date:
* must provide value
Today M-D-Y
Degree(s):
* must provide value
Medical School:
* must provide value
Are you an International Medical Graduate?
* must provide value
Yes
No
Are you ECFMG Certified?
* must provide value
Yes
No
City:
* must provide value
State:
* must provide value
Country:
* must provide value
Graduation Date:
* must provide value
Today M-D-Y
Degree(s):
* must provide value
Was your medical education interrupted?
* must provide value
Yes
No
If yes, please explain.
* must provide value
Residency Institution:
* must provide value
Specialty Area:
* must provide value
City:
* must provide value
State:
* must provide value
Date Residency Began:
* must provide value
Today M-D-Y
Date Residency Ended:
* must provide value
Today M-D-Y
Residency Graduation Date:
* must provide value
Today M-D-Y
Have you been enrolled in any other residency training programs other than the one above?
* must provide value
Yes
No
Residency Institution:
* must provide value
Specialty Area:
* must provide value
City:
* must provide value
State:
* must provide value
Date Residency Training Began:
* must provide value
Today M-D-Y
Date Residency Training Ended:
* must provide value
Today M-D-Y
Have you completed a Fellowship Program?
* must provide value
Yes
No
Fellowship Institution:
* must provide value
Specialty Area
* must provide value
City:
* must provide value
State:
* must provide value
Date Fellowship Began:
* must provide value
Today M-D-Y
Date Fellowship Ended:
* must provide value
Today M-D-Y
Have you completed any other Post Graduate Training?
* must provide value
Yes
No
Institution:
* must provide value
Specialty Area:
* must provide value
City:
* must provide value
State:
* must provide value
Date Other Post Graduate Training Began:
* must provide value
Today M-D-Y
Date Other Post Graduate Training Ended:
* must provide value
Today M-D-Y
Do you currently have any military service commitment?
* must provide value
Yes
No
If yes, please explain.
* must provide value
Do you hold an active medical license?
* must provide value
Yes
No
State:
* must provide value
Medical License Number:
* must provide value
Date License Issued:
* must provide value
Today M-D-Y
Date License Expires:
* must provide value
Today M-D-Y
Do you hold any active medical license in another state?
* must provide value
Yes
No
State:
* must provide value
Date License Issued:
* must provide value
Today M-D-Y
Date License Expires:
* must provide value
Today M-D-Y
Are you Board Certified?
* must provide value
Yes
No
Specialty Area
* must provide value
Has your medical license ever been suspended/revoked/voluntarily terminated?
* must provide value
Yes
No
If yes, please explain.
* must provide value
Have you been named in a malpractice case?
* must provide value
Yes
No
If yes, please explain.
* must provide value
Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?
* must provide value
Yes
No
If yes, please explain.
* must provide value
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?
* must provide value
Yes
No
If no, please explain.
* must provide value
Have you ever been convicted of a misdemeanor?
* must provide value
Yes
No
If yes, please explain.
* must provide value
Have you been convicted of a felony?
* must provide value
Yes
No
If yes, please explain.
* must provide value
Name:
* must provide value
Institution:
* must provide value
Position:
* must provide value
Is this your current or most recent Program Director?
* must provide value
Yes
No
Please note: it is a requirement that one of the letters of recommendation must come from the current or most recent Program Director.
Name:
* must provide value
Institution:
* must provide value
Position:
* must provide value
Personal Statement:
* must provide value
USMLE (include STEP 1, STEP 2, STEP 3) / COMLEX Report (include COMLEX 1, 2, 3):
* must provide value
Medical School Diploma:
* must provide value
Photo:
* must provide value
ECFMG certificate:
* must provide value
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
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 ______ . 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 Emergency Medicine EMEducation@UTSouthwestern.edu
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 ______ 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 to EMEducation@utsouthwetsern.edu o r mailed to Emergency Medicine Education:
UT Southwestern Medical Center
Emergency Medicine Education
5323 Harry Hines Blvd
Dallas, TX 75390-8579
Best regards,
Emergency Medicine Education
Yes, please
No thank you, I will email them separately
Selecting "Yes" will trigger an email to be sent to the applicant.
Indicate what documents are missing.
Submit
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