MGB Body Imaging Fellowship Application
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
*
Please Select
July 2027 - June 2028
Name:
*
First Name
Last Name
Email Address:
*
Alternate Email:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Home Address:
*
Phone (cell)
*
Format: (000) 000-0000.
Phone (work)
Format: (000) 000-0000.
Country of Citizenship:
*
US
Canada
Other
What is your desired visas type:
H1
J1
Other
Optional: 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
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
*
US Medical School Graduate
Canadian Medical School Graduate
International Medical School Graduate
Other
I am ECFMG certified
Yes
No
Other
Medical School
Rows
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:
Rows
Institution Name
Program Name
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:
Rows
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
Other
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
List all other states
License Information:
Rows
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
*
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Personal Statement
*
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Recent Photograph
*
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ECFMG Certificate
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Exam Results (USMLE, COMLEX, LMCC...)
*
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Letters of Reference
Please upload three letters of reference, one of which must be from your radiology residency program director.
Upload all 3 letters of reference here:
*
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