BWH & MGH MSK Fellowship Application
This is a common program application for both the BWH and MGH MSK Fellowships. Although this is a common application, they are still considered two separate programs, you will need to select one or both programs when completing this 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.
Which program are you interested in applying to (check all that apply):
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Brigham and Women's Hospital
Mass General Hospital
Name:
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First Name
Last Name
Email Address:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Home Address:
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Phone (Home)
*
Format: (000) 000-0000.
Country of Citizenship:
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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
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
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, 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
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
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
*
Browse Files
Drag and drop files here
Choose a file
Example: JohnSmith_CV.pdf
Cancel
of
Recent Photograph
*
Browse Files
Drag and drop files here
Choose a file
Example: JaneDoe_Photo.jpeg
Cancel
of
Exam Results (USMLE, COMLEX...)
*
Browse Files
Drag and drop files here
Choose a file
Example: JohnSmith_USMLE.pdf
Cancel
of
ECFMG Certificate
Browse Files
Drag and drop files here
Choose a file
Example: JaneDoe_ECFMG.pdf
Cancel
of
Personal Statement(s) (option to upload 1 PS OR 2 PS specific to MGH and BWH)
*
Browse Files
Drag and drop files here
Choose a file
Example: JameSmith_PS.pdf
Cancel
of
Letters of Reference
Please list the names and institutions of three physicians who will be writing recommendation letters for you.
Reference Names and Contacts: If an administrator will be submitting letters of recommendation on behalf of a physician please put the administrator's email address instead of the physician's email address.
*
Rows
Person's Name
Institution
Email Address
Reference 1
(Program Director or Chair whom you have worked)
Reference 2
(MSK Radiologist with whom you have worked
Reference 3
(Letter writer of your choice)
By checking the box below, you agree to waive your right to read any reference letters.
Yes, I agree
No, I do not agree
By signing below, I certify all information is true and correct to the best of my knowledge.
*
Submit Application
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