6701 Fannin Street

6701 Fannin Street

Clinical Care Center

Suite 660

Houston, TX 77030

Ifeoma Inneh

Telephone: 832-822-2791

Fax: (832) 825-9099

FELLOWSHIP APPLICATION

Please attach
recent photo /

PLEASE DO NOT WRITE IN THIS SECTION

Appointment as: ______

______
From:______To:______

I hereby apply for appointment as a Graduate Medical Trainee at Texas Children's Hospital for ______months, beginning______(with vacation, depending on length of service, being provided at a time convenient to the hospital).

PLEASE  APPOINTMENT DESIRED

 TCH/BCM Post-doctoral Pediatric Clinical Orthopaedic/Spine Research Fellow

 SICOT/TCH Pediatric Orthopaedic Research Fellow

SPECIALTY ______

PLEASE TYPE OR PRINT

Have you completed basic Orthopedic residency/registrar work?  Yes  No

Are you fluent in English?  Yes  No

Full Name: ______M.D.______M.B.B.S ______.D.S.______

D.O.______M.B.B.Ch. ______D.M.D.______

Present Address: ______

City: ______State:______Zip:______Country:______

Telephone (Main):______Cell #______

E-Mail Address: ______FaxNo.______

Permanent Address: ______

Place of Birth: ______Date of Birth: ______Married ______Single______

Citizen of: ______U.S. Social Security No.:______

U.S. Unrestricted Medical License (attach copy): Graduate Medical Training License (attach copy):

State: ______No.______State: ______No:______

State: ______No.______State: ______No:______

U.S. Medical Licensing Exams passed (attach copy of scores for each exam):

MCCQE & LMCC_____FLEX______FLEX 1______FLEX II_____NBME 1_____NBME II______

NBME III_____ USMLE 1_____USMLE 2______USMLE 3______

INTERNATIONAL MEDICAL GRADUATES (attach copies of each document)

ECFMG Certificate No. ______Type if Visa ______Hold ______Needed______

PREMEDICAL EDUCATION: InstitutionFromToDegree

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MEDICAL EDUCATION:InstitutionFromToDegree

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HOSPITAL TRAINING (do not list rotations in medical school):

HospitalLocationFromToDegree

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POSTGRADUATE EDUCATION (organized courses only):

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SPECIAL TRAINING (not already listed, such as assistantships, practice, etc.)

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BOARD CERTIFICATION

YearSpecialtyName of BoardCountry of Issuing Board

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______

ADDITIONAL INFORMATION (such as publications, summer work, extra-curricular activities):

______

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REFERENCES:Communications concerning professional ability and personal qualifications must be sent under

Separate cover directly to Ifeoma Inneh in The Department of Orthopaedic Surgery & Scoliosis at Texas Children’s Hospital from at least three physicians, preferably under whom you have served or trained. Letters of recommendation must be requested by the applicant. List references below:

”Please do not provide if already submitted to Department upon which you were interviewed”

Name / Email / Cell Number

I certify that this Application, including all attachments and supplemental information, is true and correct to the best of my knowledge. I attest to the correctness and completeness of all information furnished. I fully understand that any significant misstatement or omission from this Application constitutes cause for denial of or dismissal from this educational opportunity. I authorize a representative of the Department of Orthopaedic Surgery at Texas Children's Hospital to consult anyone who may have information bearing on my competence, ethics, character and other qualifications. I consent to the inspection, copying and release of all records and documents that may be material to evaluation of my competence, ethics, character and other qualifications. I release from any liability, to the fullest extent permitted by law, all individuals and organizations who provide information in good faith regarding my competence, ethics, character, and other qualifications, including otherwise confidential information.

SIGNATURE OF APPLICANT: ______DATE:______

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Regular Mail Address

Ifeoma Inneh

Texas Children's Hospital

Department of Orthopaedic Surgery & Scoliosis, Clinical Care Center

6701 Fannin Street, Suite 660

Houston, TX 77030

Email Address

Ifeoma Inneh:

Telephone: (832) 822-2791

Fax: (832) 825-9099

Website: