COMPLETING THE APPLICATION FOR FELLOWSHIP
Please type or print legibly in black ink.
Honors/Awards (Item 7, Page 1): List all honors/awards, including membership inhonor societies such as AOA. Specify the basis for any special recognition (i.e.,academic performance, special accomplishments, leadership, research, communityservice, etc.)
Personal Statement (Item 11, Page 3) The Personal Statement provides you with theopportunity to communicate your professional interests and achievements with regard toresearch experience and training, special projects, and professional accomplishments. Bibliographic references should be provided for all published papers. Program Directorsare also interested in your future plans as defined by your specialty goal and the numberof years you intend to devote to graduate medical education.
You may also wish to describe your personal interests, activities, and circumstances. Astranscripts of your academic accomplishments are most likely to be required, andinterruption in your medical education should be explained in the Personal Statement.
Permanent Address and Telephone Number (Item 18, Page 4): Enter the name,address, and telephone number of an individual through whom you can always becontacted (i.e., parent, relative, close friend, etc.).
Photograph: Most program directors request a photograph in order to associate a facewith the “paper work”. If you do not submit one at this time, you should be prepared toprovide one when you are interviewed.
References (Item 23, Page 5): We require the Residency Program Director’s or theDepartment Chairman’s letter as a standard reference. We require a minimum of twoadditional evaluations. References should be from faculty members or physicians whoare familiar with your credentials and are in a position to comment on your suitability forthe position you seek.
SUBMITTING THE APPLICATION FOR FELLOWSHIP
The deadline for submitting application material is November 30th. Applicationsubmissions must include a personal statement, fellowship application, updatedcurriculum vitae, and three letters of reference including one from the program director ordepartment chairman.
These should be mailed to:
Administrative Manager of Academics
Department of Physical Medicine and Rehabilitation
Attention: TBI/Neurological Rehabilitation Fellowship Application
SpauldingRehabilitationHospital
300 First Avenue
Charlestown, MA02129
PAGE ONE APPLICATION FOR FELLOWSHIP
HARVARD MEDICAL SCHOOL/SPAULDING REHABILITATION HOSPITAL
TBI/Neurological Rehabilitation Fellowship Application
NAME:
(LAST) (FIRST) (MIDDLE)
POSITION BEGINNING IN:
(MONTH) (YEAR)
1. E-MAIL:2. SOCIAL SECURITY NUMBER:
RESIDENCY EDUCATION
3. MEDICALSCHOOL or INSTITUTION
(NAME)
(CITY) (STATE/COUNTRY)
4. PM&R RESIDENCY PROGRAM:
5. DATE OF COMPLETION:
6. PROGRAM DIRECTOR:
7. HONORS/AWARDS:
MEDICAL EDUCATION
8. MEDICALSCHOOL
NAME:
CITY:
STATE/COUNTRY:
GRADUATE EDUCATION
9. GRADUATESCHOOL(S)
A. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
GRADUATE DEGREE (IF ANY):
AREA OF STUDY:
B. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
GRADUATE DEGREE (IF ANY):
AREA OF STUDY:
PAGE TWO APPLICATION FOR FELLOWSHIP
UNDERGRADUATE EDUCATION
10. UNDERGRADUATECOLLEGE(S)
A. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
DEGREE (IF ANY):
MAJOR:
B. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
DEGREE (IF ANY):
MAJOR:
PAGE THREE APPLICATION FOR FELLOWSHIP
11. PERSONAL STATEMENT (SEE INSTRUCTIONS. USE ADDITIONAL SHEET IF NECESSARY)
12. 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 ______
(MONTH/YEAR)
NUMBER OF YEARS COMMITTED
PAGE FOUR APPLICATION FOR FELLOWSHIP
13. ECFMG Registration (if applicable):______
14. PRESENT ADDRESS
______
(STREET)
______
(CITY) (STATE) (ZIP)
15. PRESENT PHONE NUMBERS:
DAY:______
EVENING:
16. VISA STATUS (IF APPLICABLE)
PERMANENT
TEMPORARY – SPECIFY
J-1
H-1
17. CITIZENSHIP
U.S. OTHER
ATTACH RECENT
PHOTOGRAPH
(SEE INSTRUCTIONS)
18. PERMANENT ADDRESS:
______
C/O (NAME OF PERSON THROUGH WHOM I CAN ALWAYS BECONTACTED)
______
(STREET)
______
(CITY) (STATE) (ZIP)
PAGE FIVE APPLICATION FOR FELLOWSHIP
19. I plan to take the examinations checked below before I begin the Graduate Medical Education program forwhich I am now applying:
USMLE, STEP 1 USMLE, STEP 11 USMLE, STEP 111
20. I have already passed the examinations checked below on the dates indicated:
NMBE, PART 1______NMBE, PART 11______NMBE, PART 1______
(DATE) (DATE) (DATE)
USMLE,STEP 1______USMLE, STEP 11____ USMLE, STEP 111______
(DATE) (DATE) (DATE)
FLEX: ______
(DATE) (State[s] ofLicensure)
21. LIST ANY ADDITIONAL EXAMINATIONS PASSED (FMGEMS, DAY 1; FMGEMS, DAY 2; VQE, DAY 1;VQE, DAY 2; ECFMG MEDICAL SCIENCE EXAM);
22. I have read and I understand the instructions for the completion of this application. I certify that theinformation submitted on these application materials is complete and correct to the best of my knowledge: Iunderstand that any false or missing information may disqualify me for this position.
SIGNATURE OF APPLICANT:______DATE:______
NOTE: THE SIGNATURE AND DATE ON EACH APPLICATION PAGE MUST BE ORIGINAL.
23. LETTERS OF REFERENCE, IN ADDITION TO RESIDENCY PROGRAM DIRECTOR’S LETTER, HAVEBEEN REQUESTED FROM THE FOLLOWING INDIVIDUALS:
A. NAME AND TITLE:
INSTITUTION:
ADDRESS:
B. NAME AND TITLE:
INSTITUTION:
ADDRESS:
C. NAME AND TITLE:
INSTITUTION:
ADDRESS:
I HEREBY WAIVE ACCESS TO THE ABOVE LETTERS AND
WILL SO INFORM THE AUTHORS.
24. (CHECK ONE)
I DESIRE ACCESS TO THE ABOVE LETTERS AND WILL SOINFORM THE AUTHORS.
______
SIGNATURE DATE
______
NAME OF APPLICANT -TYPE OR PRINT
NOTE: THE SIGNATURE AND DATE ON THIS STATEMENT MUST BEORIGINAL.
Rev. 10/07/09