AGCES Fellowship Application Form
General Information
Desired Starting Year of Fellowship
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
State License Number
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why are you interested in the AGCES Fellowship?
*
Short response. Personal statement to be uploaded on uploads page.
What are your long-term career goal in endometriosis, adenomyosis, and andomyoma care?
*
Short response. Personal statement to be uploaded on uploads page.
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Education and Training
Premedical Education
Name of College or University
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Attended
*
Degree Earned
*
Medical Education
Name of Institution
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Attended
*
Degree Earned
*
Internship
Name of Institution
Name of Affiliated Hospital
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Attended
Residency
Name of Institution
*
Type of Residency
*
Dates
*
Chairman
*
Department
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Fellowship
Name of Institution
Type of Fellowship
Dates
Director
Department
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Training
Please list any other training here.
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Licensure and Billing Information
State Board of Medical Examiners
License Number
Date
-
Month
-
Day
Year
Date
National Board of Medical Examiners
License Number
Date
-
Month
-
Day
Year
Date
BNDD (DEA) Registration (Narcotic Lic.):
License Number
Date
-
Month
-
Day
Year
Date
State Registration (Narcotic Lic.):
License Number
Date
-
Month
-
Day
Year
Date
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Board Eligibility and/or Board Certification
Are you Board-Eligible or Board-Certified in OBGYN?
*
Yes
No
Expiration Date
-
Month
-
Day
Year
Date
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Uploads
Please upload one photograph of yourself.
*
Browse Files
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Please upload your CV.
*
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Please upload a list of publications.
*
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Please upload your personal statement.
*
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Describe your interest in pursuing advanced fellowship training in endometriosis, adenomyosis, and adenomyoma. Discuss your long-term goals and commitment to multidisciplinary, patient-centered care. (1 page maximum)
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Please upload three letters for recommendation, including one from your residency program director.
*
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All letters should be addressed to 'Dr. Camran Nezhat'.
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Please upload case log (if applicable).
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Payment
Application Fee
*
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( X )
AGCES Fellowship Application
This is a non-refundable application fee.
$
375.00
Quantity
1
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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