UCSD PAIN MEDICINE FELLOWSHIP APPLICATION

INSTRUCTIONS FOR THE UNIVERSAL APPLICATION FOR PAIN MEDICINE FELLOWSHIP:

PLEASE READ CAREFULLY

REQUIRED DOCUMENTS

IN SEPARATE DOCUMENTS, PLEASE ATTACH YOUR MOST RECENT CURRICULUM VITAE and a PERSONAL STATEMENT.

1.  Curriculum Vitae: Your curriculum vitae should include but not be limited to the following:

a.  Additional Research Work

b.  Publications and Publication Contributions (i.e., abstracts, manuscripts, peer-reviewed articles, and/or presentations),

c.  Professional Memberships, Attendance at Professional Society Meetings (if applicable), Community Services, Certifications, Honors, Licenses, etc.

2.  Personal Statement: Please include additional information that was not included in your curriculum vitae. Please also provide information concerning your future medical short and long terms goals.

3.  Current License: Please include a copy of your current medical license. This may be a temporary residency license.

4.  Optional Additional Information: The following Licenses are required if accepted into the UCSD Pain Medicine fellowship. Please include copies of the following licenses if you currently have them.

a.  California State Medical License

b.  ACLS/BLS

c.  DEA

SUBMITTING THE UNIVERSAL APPLICATION FOR PAIN MEDICINE FELLOWSHIP

Mail this application along with the above mentioned documentation to:

Mark S. Wallace, MD, Fellowship Program Director

Attention: Debra Kerrigan, Fellowship Coordinator

UCSD Anesthesiology Center for Pain Medicine Fellowship Program

9300 Campus Point Drive, MC 0924

La Jolla, CA 92037-1300

You should submit (via US mail) all pages of the Universal Application for Pain Medicine Fellowship, with original signatures, to each program to which you wish to apply. It is the applicant’s responsibility to arrange to submit required supplementary materials (transcripts, letters of evaluation, etc.) by the designated program's stated deadline.

POSITION BEGINNING IN ______(Month/Year)
1. Name Last First Middle
2. Social Security Number 3. Address: Street City State Zip code
4A. Home Telephone Number 4B. Cellular Telephone Number 4C. Alternative Telephone Number
5A. Preferred Email Address 5B. Alternative Email Address


APPLICATION FOR PAIN FELLOWSHIP - PAGE ONE

6. Name of Current Hospital / Institution City State Zip code

APPLICATION FOR PAIN FELLOWSHIP - PAGE TWO

10. PLEASE COMPLETE THE FOLLOWING CONCERNING ANY REVOCTIONS AND/OR DENIED PRIVILEDGES

Have you ever been denied a license and/or privileges? Yes No

If YES, please provide information concerning the incident (s): ______

______

CITIZENSHIP
11. CITIZENSHIP
U.S.
Other (Specify) ______/ 12. VISA STATUS (IF APPLICABLE)
Permanent
Temporary Specify: H1 J1
13.  PERMANENT ADDRESS (C/O NAME OF PERSON THROUGH WHOM I CAN ALWAYS BE CONTACTED)
Street: ______
City: ______State: ______Zip Code: ______
14. PERMANENT TELEPHONE NUMBER : ______

15. SERVICE OBLIGATIONS (NATIONAL HEALTH SERVICE CORPS, ARMED FORCES SCHOLARSHIP, STATE PROGRAMS, ETC.)

I AM NOT REQUIRED TO FULFILL ANY SERVICE OBLIGATIONS

I AM COMMITTED TO FULFILL A SERVICE OBLIGATION BEGINNING

(MO /YR)

NUMBER OF YEARS COMMITTED

*ATTACH RECENT PHOTOGRAPH (OPTIONAL)

*Photograph: Most program directors request a photograph in order to associate a face with the "paper work". If you do not submit one at this time, you should be prepared to provide one when you are interviewed.


APPLICATION FOR PAIN FELLOWSHIP - PAGE THREE

16. I have already passed the examinations checked below on the dates indicated:

USMLE, STEP I: USMLE, STEP II: USMLE, STEP III:

(Date) (Date) (Date)

Actual Score ______Actual Score ______Actual Score ______

COMLEX I: COMLEX II: COMLEX III:

(Date) (Date) (Date)

Actual Score ______Actual Score ______Actual Score ______

17. LIST SPECIALITIES (if applicable):

Board ______Year Certified ______Exp.____/____

Board ______Year Certified ______Exp.___ /____

(c) Name / Institution / Address
Title / Department / City, State, Zip Code

18. LETTERS OF REFERENCE HAVE BEEN REQUESTED FROM THE FOLLOWING INDIVIDUALS:

(a) Name / Institution / Address
Title / Department / City, State, Zip Code
(b) Name / Institution / Address
Title / Department / City, State, Zip Code

Deans Letter(s) (if applicable)

(d) Name / Institution / Address
Title / Department / City, State, Zip Code

19. Will you be available for appointment in July 1? (YES or NO) ______

I have read and understand the instructions for the completion of this application. I certify that the information submitted on this application is complete and correct to the best of my knowledge. I understand that any false or missing information may disqualify me for this position.

NOTE: THE SIGNATURE AND DATE ON EACH APPLICATION MUST BE ORIGINAL.

Signature of Applicant: Date: