Email to:

THE CLEVELAND CLINIC EDUCATIONAL FOUNDATION/ NA23

9500 Euclid Avenue uCleveland, Ohio 44195

216/444-569O

Fax 216/636-0110

APPLICATION FOR VISITING RESIDENT/FELLOW

(Please print or type application in its entirety and attach all requested documents)

Full Name: ______SSN: ______-______-______

Home Address: ______E-mail: ______@______

City, State, Zip: ______Phone: ______/______

NPI Number: ______

Rotation Requested: ______Dates requested: ______- ______

Have you been a visiting resident/fellow at Cleveland Clinic before? ¨ Yes ¨ No

If yes, when? _____/_____/_____ What Service? ______

Medical School Information

Medical School:______Date of Graduation: ______

mm/dd/year

Will the resident be returning to their home hospital for Continuity Clinic or other activity during this rotation? ¨ Yes ¨ No

If so, please state dates and am/pm ______

Will you be attending didactic sessions at your home program? ¨ Yes ¨ No

Will you be taking call at your home hospital? ¨ Yes ¨ No

Are you taking any vacation during your rotation? ¨ Yes ¨ No

Do you have a Permanent Ohio Medical License? ¨ Yes ¨ No

If no, do you currently hold an Ohio State Medical Board Training Certificate? ¨ Yes ¨ No


Please list all U.S. Residency or Fellowship training in chronological order in addition to attaching a copy of current CV:

Current Residency/Fellowship Training
Specialty / Hospital / City / State / Graduate Level / Begin Date / End Date
Previous Residency/Fellowship Training
Specialty / Hospital / City / State / Graduate Level / Begin Date / End Date
Specialty / Hospital / City / State / Graduate Level / Begin Date / End Date
Specialty / Hospital / City / State / Graduate Level / Begin Date / End Date

□ I agree to abide by all Cleveland Clinic policies and procedures.

□ I Certify that the information given on this application is true, accurate and complete.

______

APPLICANT'S SIGNATURE DATE

AUTHORIZATION FOR EXTRAMURAL ELECTIVE BY TRAINING PROGRAM DIRECTOR 0R AUTHORIZED INDIVIDUAL OF THE SPONSORING INSTITUTION

______

SPONSORING INSTITUTION APPROVAL DATE

Cleveland Clinic will ensure a non-discriminatory environment regarding personnel/employment practices. These practices are administered without regard to race, color, religion, sex, sexual orientation, gender identity, genetic information, national origin, ancestry, handicap, age, pregnancy, marital status, disability, military status, veteran or Vietnam Era Veteran. Cleveland Clinic

complies with all federal regulations, and is committed to a program of equal opportunity which is consistent with the goals, mission and values of our institution.

Emergency Contact Information:

Name & Relationship of Contact:______Phone: ______