BWH/DFCI Cancer 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, national origin, disability status, protected veteran status, gender identity, sexual orientation, pregnancy and pregnancy-related conditions or any other characteristic protected by law.
Program of Interest
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Cancer Imaging Program (CIP) Fellowship
3 month PET-CT/General Cancer Imaging Fellowship
12 month PET-CT Cancer Imaging Fellowship
Desired Start Date
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Name:
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First Name
Last Name
Email Address:
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Date of Birth:
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-
Month
-
Day
Year
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Home Address:
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Phone (Home)
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-
Area Code
Phone Number
Country of Citizenship:
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US
Canada
Other
What is your desired visas type:
H1
J1
Other
Optional: What sex were you assigned at birth, on your original birth certificate?
Female
Male
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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
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Other
Optional: Preferred Pronoun
she/her/hers
he/him/his
they/them/theirs
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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
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
Program Name
Dates of Attendance
Internship
Residency 1
Residency 2
Other
Certifications and Licenses
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?
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Yes
No
Other
Are you interested in the ABR 4 Year Alternative Pathway?
Yes
No
Unsure
ABR Core Exam Date
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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
Other
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?
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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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Upload a File
Example: JohnSmith_CV.pdf
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Personal Statement
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Example: JameSmith_PS.pdf
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Recent Photograph
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Upload a File
Example: JaneDoe_Photo.jpeg
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Exam Results (USMLE, COMLEX, LMCC...)
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Upload a File
Example: JohnSmith_USMLE.pdf
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ECFMG Certificate
Upload a File
Example: JaneDoe_ECFMG.pdf
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Letters of Reference
Please list the names and institutions of three physicians who will be writing recommendation letters for you.
Reference Names and Contacts
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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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