BWH Joint Program in Nuclear Medicine (JPNM) Application
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, gender identity, sexual orientation, pregnancy and pregnancy-related conditions or any other characteristic protected by law.
Name:
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First Name
Last Name
Desired Start Date (mm/yyyy)
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Select Training Pathway
12 Months
24 Months
36 Months
Email Address:
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Date of Birth:
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-
Month
-
Day
Year
Date Picker Icon
Home Address:
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Phone (Home)
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-
Area Code
Phone Number
Country of Citizenship:
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US
Canada
Other
What is your desired visas type:
H1
J1
Other
Optional: What sex were you assigned at birth, on your original birth certificate?
Female
Male
Decline to answer
Optional: Current Gender Identity (check all that apply)
Female
Male-to-Female(MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Male
Female-to-Male(FTM)/Transgender Male/Trans Man
Decline to answer
Other
Optional: Preferred Pronoun
she/her/hers
he/him/his
they/them/theirs
Decline to answer
Other
Optional: Self-Identification (select all that apply)
Asian
Black or African American
American Indian or Alaska Native
Hispanic, Latino, or of Spanish Origin
Native Hawaiian or Pacific Islander
White
Decline to answer
Other
Education and Training
I am a
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US Medical School Graduate
Canadian Medical School Graduate
International Medical School Graduate
Other
I am ECFMG certified
Yes
No
Other
Medical School
Institution Name
Degree Received
Dates of Attendance
Med School 1
Med School 2
Premed School 1
Premed School 2
Medical and Specialty Training
Previous post-graduate training positions:
Institution Name
Program Name
Dates of Attendance
City/ State
Country
Contact Person
Internship
Residency 1
Residency 2
Current Position
Other
Certifications and Licenses
USMLE, COMLEX, or LMCC Results:
Date Taken
Score
Step 1
Step 2 CK
Step 2 CS
Step 3
COMLEX Level 1
COMLEX Level 2 CE
COMLEX Level 2 PE
COMLEX Level 3
LMCC
Board Certifications
Speciatly/Sub-Specialty Board Name
Date Certified
Board Certification
Board Certification
Board Certification
Have you ever been examined by any specialty board, but failed to pass?
Yes
No
If yes, please provide explanation:
Yes/No
If yes, provide Board name
If not certified, have you applied for a certification examination?
Yes
No
If No, do you intend to apply for certification examination?
Yes
No
If Yes, have you been accepted to take a certification examination?
Yes
No
Are you planning to, or have you applied for, a certification examination by a second or third specialty board?
Yes
No
Are you planning to, or have you applied for, a certification examination by a second or third specialty board?
Yes
No
Oral Exam dates:
Written Exam dates:
ABR Core Exam
Have you taken the ABR Core Exam?
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Yes
No
Other
Are you interested in the ABR 4 Year Alternative Pathway?
Yes
No
Unsure
ABR Core Exam Date
-
Month
-
Day
Year
Date
Result
Pass
Fail
Overall Score
Physics Subscore
Medical Licensing
State(s) in which you are licensed to practice medicine:
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MA
None
Other
License Information:
State
License Number
Expiration Date
Medical License 1
Medical License 2
Medical License 3
Have you ever been denied or lost a state license?
*
No
Yes
If yes, please explain:
Additional Data:
Yes/No
Has your professional employment ever been suspended, diminished, revoked or terminated at any hospital or healthcare facility or are any proceedings which may result in any such action currently pending?
Yes
No
Has your medical staff appointment/privileges ever been limited, suspended, diminished, revoked, refused, terminated, restricted, not renewed, relinquished (whether voluntarily or involuntarily) at any hospital or healthcare facility or are proceedings currently pending which may result in any such action?
Yes
No
Have you ever withdrawn (or voluntarily relinquished) your application for appointment, reappointment, or privileges or resigned from the medical staff, because a disciplinary action or loss or restriction of clinical privileges was threatened or before a decision about your appointment and/or privileges was rendered by a hospital's or healthcare organization's governing board?
Yes
No
Have you ever been the subject of disciplinary proceedings at any hospital or healthcare facility?
Yes
No
Have you ever been investigated for scientific misconduct?
Yes
No
Have you ever been suspended, sanctioned or restricted from participating in any private, federal or state health insurance program (e.g., Medicare, Medicaid or Blue Cross/Blue Shield)?
Yes
No
Upload Documents (must be in PDF format, JPG for photo)
File titles: (YourName_DocumentName.pdf, Example: JohnSmith_CV.pdf, JaneDoe_USMLE.pdf, etc...)
Curriculum Vitae
*
Example: JohnSmith_CV.pdf
Personal Statement (approximately 500 words) briefly describing your background, previous training experiences, and why you wish to pursue residency training in Nuclear Medicine.
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Example: JohnSmith_PS.pdf
Recent Photograph
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Example: JohnSmith_Photo.jpeg
Exam Results (USMLE, COMLEX, LMCC...)
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Upload a File
Example: JohnSmith_USMLE.pdf
Cancel
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ECFMG Certificate
Example: JohnSmith_ECFMG.pdf
Evidence of Specialty Board Certification and current licenses to practice medicine in the US (if applicable).
Browse Files
Example: JohnSmith_BoardCertification.pdf
Cancel
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For applicants interested in pursuing additional research opportunities, include a statement summarizing interest and purpose of research (100-150 words)
Browse Files
Example: JohnSmith_Research.pdf
Cancel
of
Letters of Reference
Please list the names and institutions of three physicians who will be writing recommendation letters for you. *Letters must be from within the past two years
Reference Names and Contacts Letters must be from within the past two years
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Person's Name
Institution
Email Address
Reference 1
Reference 2
Reference 3
By signing below, I certify all information is true and correct to the best of my knowledge.
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Submit Application
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