Sports Neurology Center

Kevin E. Crutchfield, MD, Director

The Sandra and Malcolm Berman Brain & Spine Institute

5051 Greenspring Avenue · Baltimore MD 21209

phone ~ 410-601-1920 · fax ~ 410-601-1910 ·

Sports Neurology Fellowship Application (2 of 2)

I am applying to BEGIN the Sports Neurology Fellowship Program in: / 2017 / 2018
last name / first name / middle name
street address
city / state / zip
phone contact #1 / phone contact #2 / email
medical school / location / degree / date conferred
residency type / institution / dates
residency type / institution / dates
current position / institution / dates
Citizenship: / US / Other / Visa status
Desired length of fellowship: / 1 year / 2 years / Undecided at this time
Preferred dates of fellowship:
Please attach the following with your completed application:
·  Curriculum vitae (include current work status)* / ·  Official medical school transcript
·  Statement of personal & professional goals* / ·  USMLE/COMLEX scores I, II, & III
·  3 letters of recommendation―must be originals on official stationary (no faxes accepted) and sent directly to:
Tzipora Sofare, MA, at the address in header above* / ·  Letter of good standing from current residency program/employer that includes clear criminal background check* and current drug screening*
(*can be provided separately)
* / These 3 items and this completed application must
be received before applicant’s eligibility for an
on-site interview can be determined. If the applicant
is selected for an on-site interview, all other items listed in the right column must be received before
the scheduled interview. / ·  Residency verification
·  Passport-sized photo (1)
5. How did you hear about this fellowship opportunity?

~ Continued ~

Comments (use this space to list any additional residency information, continue with information from the front page, or make any comments you would like).
Applicant’s Certification
I hereby certify that all of the information I have provided with this application is complete and accurate.
I understand that any appointment will be contingent on my providing the necessary employment eligibility documentation prior to the appointment.
applicant’s signature / date
For office use only:
Complete application received:
Dates of fellowship: to
Status: r Accept r Pending r Reject
Comments: