Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permanent Address, if different from above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Fellowship Specialty Program are you interested in?
*
Cerebrovascular and Endovascular (2 Year)
Complex and Minimally Invasive Neurosurgery Spine
Interventional Spine
Term
*
1 Year
2 Year
Undergraduate. Include: Institution | Degree | Dates of Attendance
*
Medical School. Include: Institution | Degree | Dates of Attendance
*
Residency. Include: Institution | Degree | Dates of Attendance
*
If you are an International Medical Graduate, are you E.C.F.M.G. certified?
*
Yes
No
If you answered yes to being E.C.F.M.G. certified. Please specify Certificate Number and Issue Date
Post Graduate Work Experience, including Fellowship(s). Include: Institution | Specialty | Dates of Attendance
Have you taken and passed USMLE Step(s) 1, 2 Clinical Knowledge (CK), and 3?
*
Yes
No
Steps 1 & 2 are completed; Step 3 is not completed but scheduled
Are you Authorized to work in the U.S.?
*
Yes
No
Are you a US Citizen or Permanent Resident?
*
Yes
No
Are you seeking work authorization and sponsorship? Swedish Neuroscience Institute sponsors H1B visas ONLY. If you require a J1, J1 Conrad Waiver or an O1 visa you will not be considered eligible for the fellowship.
*
Yes
No
Please list current and expired State Medical Licenses. Include: License Number | State | Duration
Do you have an active unrestricted DEA License?
*
Yes
No
Do you have an NPI (National Provider Identifier)?
*
Yes
No
Are you Board Certified or Board Eligible in the United States or Canada?
*
Yes
No
Has your medical license ever been suspended / revoked /voluntarily terminated?
*
Yes
No
If you answered yes to having your medical license suspended / revoked / voluntarily terminated, please specify
Have you ever been named in a malpractice case?
*
Yes
No
If you answered yes to being named in a malpractice case, please speficy
Have you ever been convicted of a misdemeanor in the United States?
*
Yes
No
If you answered yes to being convicted of a misdemeanor in the United States, please specify
Have you ever been convicted of a felony in the United States?
*
Yes
No
If you answered yes to being convicted of a felony in the United States, please specify
Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?
*
Yes
No
If you answered yes, please specify
Are you able to carry out the responsibilities of a fellow in our program, including functional requirements, cognitive requirements, and interpersonal communication requirements with or without reasonable accommodations?
*
Yes
No
I understand that in order for my application to be processed, I will need to send a copy of my Curriculum Vitae (CV), Personal Statement, Minimum of two letters of recommendation, Relevant Exam reports (IE United States Medical Licensing Examination Scores) and a recent headshot to swedishfellowshipinbox@swedish.org
*
I Understand
Disclaimer: I understand that by completing this fellowship application I am expressing my interest in a fellowship opportunity with the Swedish Neuroscience Institute (SNI). The completion of this application does not constitute an application for employment with SNI or Swedish Medical Center, nor does it guarantee acceptance to SNI fellowship training. Should I be favorably considered for an SNI fellowship, I understand I will be required to complete a separate employment application.
*
I Understand
Signature
*
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