Nuclear Medicine Application
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Citizenship
*
Visa Type:
Expiration Date
Permanent Resident
Please Select
Yes
No
Education & Training
Undergraduate College
*
Degree
*
Year Completed
*
Medical School
*
Degree
*
Year Completed
*
Internship Institution
*
Type of Training
*
Dates
*
Residency Institution
*
City, State
*
Dates
*
Other Institution
City, State
Dates
Licensure
Step 1
*
Please Select
USMLE
COMLEX
Date
*
Results
*
Please add score if available: Pass 250
Step 2 CS
Please Select
USMLE CS
COMLEX CE
*If available
Date
Results
Please Select
Pass
Fail
Step 2 CK
*
Please Select
USMLE CK
COMLEX PE
Date
*
Results
*
ex: Pass 250
Step 3
*
Please Select
USMLE
COMLEX
Date
*
Results
*
ex: Pass 250
American Board of Radiology Exams:
Rows
Date Taken
Results
Core Exam
Certifying Exam
State Licensed to Practice
License Number
Expiration Date
-
Month
-
Day
Year
Date
Have you ever been denied or lost a state license? If yes, please attach and explanation below
*
Yes
No
Application Documents
Curriculum Vitae
*
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One-Page Personal Statement
*
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Deans Letter (MSPE)
*
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USMLE Scores for Steps 1-3. COMLEX Scores may be substituted for USMLEs
*
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You may upload more than one file, if needed.
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Medical School Transcripts
*
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Portrait Photo
*
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Optional Documents
Medical School Diploma
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Other
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International Medical Graduates
ECFMG Certificate
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Evidence of previous training in the United States (if applicable)
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Save
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