BWH Abdominal Imaging and Intervention Fellowship Application Form
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.
Program Year
July2024-June2025
Program Track:
1yr Abdominal Imaging and Intervention
2-year Abdominal Imaging and Intervention and Evidence-Based Imaging and Informatics
2-yearAbdominal Imaging and Intervention and Image Guidance, Precision Diagnosis and Therapy
Name:
*
First Name
Last Name
Email Address:
*
Alternate Email:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Home Address:
*
Phone (cell)
*
-
Area Code
Phone Number
Phone (work)
-
Area Code
Phone Number
Country of Citizenship:
*
US
Canada
What is your desired visas type:
H1
J1
What sex were you assigned on your birth certificate (optional)
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
Optional: Preferred Pronoun
she/her/hers
he/him/his
they/them/theirs
Decline to answer
Optional: Self-Identification (optional) (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
Education and Training
I am a
US Medical School Graduate
Canadian Medical School Graduate
International Medical School Graduate
I am ECFMG certified
Yes
No
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
Degree Received
Dates of Attendance
Internship
Residency 1
Residency 2
Other
Certifications and Licenses
USMLE Step 1 Date:
-
Month
-
Day
Year
Date
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
ABR Core Exam
Have you taken the ABR Core Exam?
Yes
No
ABR Core Exam Date:
-
Month
-
Day
Year
Date
Result
Pass
Fail
Overall Score
Physics Subscore
Are you interested in the ABR 4 Year Alternative Pathway?
Yes
No
Unsure
Medical Licensing
State(s) in which you are licensed to practice medicine:
*
MA
None
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:
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
*
Recent Photograph
*
Exam Results (USMLE, COMLEX, LMCC...)
*
ECFMG Certificate
Personal Statement (please include date and signature)
*
Letters of Reference
Please list the names and institutions of three physicians who will be writing recommendation letters for you.
Reference Names and Contacts
*
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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