Name

University of California, San Diego

Division of Gastroenterology

Universal Application

Please download this application and type in your responses.

Enter your name on each page of this application.

Application for:

___ Advanced Endoscopy Fellowship

___ IBD Postgraduate Training

___ Liver Epidemiology Fellowship

Section I – Personal Data

Last:

First:

Middle Initial:

Home Address

Street:

City:

State:

Zip:

Contact Information (place an “x” next to your preferred contact number/email)

___Home Telephone:

___Work Telephone:

___Cell:

___Pager:

___Email:

Social Security Number:_____-___-______Country of Citizenship:

Date of Birth: Place of Birth:

Marital Status:Number of Dependents:

U.S. Citizen? ___Yes ___ No. If “No,” what is your visa status:

Permanent Resident ___J1__ H1___Other___

ECFMG Number:

Section II – Race / Ethnicity (optional)

Providing information on race and ethnicity is optional. If you decline to provide this information, it will in no way affect consideration of your application. This information will be used for the purpose of ensuring that the interview and application processes are free from inequities with respect to age, race or ethnicity.

___American Indian or Alaskan Native ___ Caucasian, not of Hispanic origin

___ Asian or Pacific Islander ___ Hispanic

___ African American, not of Hispanic origin___Other ______

Section III – Principal Area(s) of Interest

___Clinical Practice

___Clinical Outcomes Research (Studies related to patients or disease

processes that involve direct contact between the investigator and

humans)

___Basic Science Research (Studies aimed at investigating cellular function,

molecular biology and pathophysiology using human materials or

experimental models)

Section IV – USMLE Scores (Indicate raw totals and percentiles):

Step I
Step II
Step III

Section V – Education

Education / Institution / City/State / Dates of Attendance / Degree Awarded
Month/Yr Received
Medical School
Graduate School
Internship
Residency
Fellowship

Section VI – Licensure

State / Issue Date / Expiration Date / Number
  1. Have you ever been denied a license, permit or privilege of taking an examination by any licensing authority? Yes ___ No ___
  2. Have you ever had a license encumbered in any away (i.e., revoked, suspended, surrendered, restricted, limited, placed on probations)? Yes ___ No ___
  3. Have you ever been named in a malpractice suit? Yes ___No ___

If you answered “Yes” to any of these questions, you must attach and sign a detailed explanation.*

Section VII – Certification

Board:Year Certified:

Board:Year Certified:

Section VIII – Honors

Specify honors/awards received. Describe in a paragraph your previous research experience or current interests.

Section IX – References

Four original letters of recommendation are required for each program to which you are applying. One letter must be from either the Department Chair or Program Director of every accredited U.S. residencies in which you have served. List your references below:

NameTitleInstitution

1.

2.

3.

4.

Section XI – Additional Documentation / Checklist

Copy of USMLE Scores / Photograph
Curriculum Vitae / (3) Letters of Reference
Personal Statement

Applicant Signature: ______

Application Date: ______

Section X – Personal Statement

Outline your interests in GI/Hepatology/Advanced IBD/Endoscopy and include a description of your career goals after you complete your fellowship training.

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