ALBERT EINSTEIN COLLEGE OF MEDICINE
DEPARTMENT OF PSYCHIATRY
AND BEHAVIORAL SCIENCES
ADDICTION PSYCHIATRY
FELLOWSHIP TRAINING
APPLICATION
Please print clearly in black ink or type. Application Date: / /
Application for Fellowship in: Beginning date: / /
Name (in full, LAST, FIRST, MI):
PERSONAL DATA
Social Security #: / Date of Birth (Optional):
Present Address:
(Street, City, State) / Citizen of U.S.: Yes ___ No ___
(If Not)
VISA Type:
Status:
Telephone #: / Fax #: / Beeper #:
EDUCATION
Medical School & Location / From - To / Month & Year of Graduation
PROFESSIONAL, POSTGRADUATE, HOSPITAL EXPERIENCE
Hospital or Institution: (include dates) / City & State / Title / Specialty or
Service
MEDICAL CREDENTIALS
National Boards /USMLE
Part I: Part II: Part III: / ECFMG#______
(PLEASE LIST DATE, SCORE, & NO. OF TIMES TAKEN FOR EACH)
Basic:
Clinical:
English: / FLEX:
Date:
Score:
New York State Medical License # / Other State(s) License:
Board Certification:

CONTINUED ON BACK

AECOM PSYCHIATRY AND BEHAVIORAL SCIENCES
ADDICTION PSYCHIATRY FELLOWSHIP APPLICATION
(Page 2)
Experience:(Include research, practice, work, graduate school, etc.)
Publications, presentations and special recognitions:
Have you ever been found guilty of unprofessional conduct, professional misconduct, or
negligence in any profession? YES (Explain) No
Are charges now pending against you for unprofessional conduct or negligence in any
profession? YES (Explain) No
Have you ever surrendered any license in lieu of disciplinary procedures? YES (Explain) No
Have you ever resigned from any academic institution or health care facility in order to
avoid the imposition of disciplinary measures or curtailments of privileges in any way? YES (Explain) No
Have you ever been convicted of a crime (other than a motor vehicle violation, juvenile
offense or matter sealed by court)? Are there any outstanding warrants against you? YES (Explain) No
Languages Spoken:
We are equal opportunity employers and are committed to the principles of equal employment opportunity for all applicants without regard to race, color, religion, sex, national origin, sexual orientation, legally defined handicap, age or veteran status.
RELEASE FROM LIABILITY
I concur that immunity be extended specifically to all persons and institutions furnishing information of my qualifications to the program, and to its affiliated hospitals. Such immunity shall cover all acts and statements made in good faith and without malice.
______
SIGNATURE OF APPLICANT DATE
To complete this application please send the following:
1. Completed application
2. Resume or C.V.
3. Photocopies of medical school diploma, transcripts, licence(s), ECFMG Certificate
4. Three (3) letters of professional reference
5. Letter from previous training director / SEND TO:
MERRILL HERMAN, M.D.
ALBERT EINSTEIN COLLEGE OF MEDICINE
Department of Psychiatry, Belfer 403
1300 Morris Park Avenue
Bronx, N.Y. 10461
Telephone: 718-430-3080