Otologic Fellowship Program

THE OTOLOGY GROUP OF VANDERBILT

1215 21st Avenue South

Suite 7209

Nashville, Tennessee 37232-8605

Attn: Betty Leslie Warner, C-TAGME

Telephone: 615.343.6972 Facsimile: 615.875.5559

Application Deadline is June 1, 2016

Application For Fellowship Beginning July 1, 2017

Please complete and attach all information requested, utilizing “N/A” as appropriate. Applications containing blanks, and/or missing attachments, will not be considered. Thanks!

General Information:

Name

Address

City State/Zip

Phone: [Work] [Home] [Cell]

E-Mail Address:

Citizenship: Visa Type? Social Security #

Present Activity:

Resident: Program

Military: Branch/Duty Station

____ Reserve or National Guard Status

Are you obligated, through a health professions loan, for military obligation?

Academic/Private Practice: Group Name/Location

Other (specify):

Licensure/Certification:

ACLS: Exp. Date:

PALS: Exp. Date:

BLS: Exp. Date:

DEA Reg #: Exp. Date:

Board Certification: Name: Recert. Date:

State Medical License(s):* Type: Number: State: Exp. Date:

*A TN state medical license is not required to practice as a fellow in our Program. Training waiver applies.

Have you been party to any malpractice liability claims, suits, and/or settlements?

Yes ___ No ___ (If yes, please attach a summary)

CRIMINAL RECORD: Have you ever been convicted of a crime, other than a minor traffic violation? If so, please explain:

REFERENCES: Please submit names and addresses of three physicians who are acquainted with your academic and/or professional experience and your personal character:

(1)

(2)

(3)

Supplemental Information Required:

1.  Photograph

2.  Two letters of recommendation, one of which is from the Program Director of your residency training program. You may submit more than two letters, if you desire; however, only two are required. Please have these mailed to us directly. Do not include as part of application.

3.  A current Curriculum vitae per normal format and including:

·  Colleges and Universities Attended (include dates and degrees)

·  Medical School, Dates of Attendance, Date of Degree(s)

·  Postgraduate Training, other than above (Fellowship, Courses in Basic Science, Summer

Research, etc. Include Location, Type of Activity, and Dates)

·  Membership in Honorary/Professional Societies

·  Membership in Scientific and/or Professional Organizations

·  Honors/Awards

·  Work/Research Experience

·  Publications

·  Language Fluency

·  Hobbies and Interests

4.  Copy of medical school transcript [does not need to be sent directly from your school].

5.  Proof of ECFMG certification, if applicable.

*ECFMG certification is required for IMGs who come to Vanderbilt for clinical training. ECFMG is an authorized agency to sponsor a J-1 visa. For the purpose of residency training, Vanderbilt accepts J-1 visas only.*

6.  Personal Statement including career objectives.

How did you hear about our Fellowship Program?

I certify that the information listed above, and on the attached Curriculum vitae, is correct.

Signature

(Full Legal Signature)

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