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Internventional-application - interventional _application

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ST. LOUIS UNIVERSITY HOSPITAL
INTERVENTIONAL CARDIOLOGY
FELLOWSHIP PROGRAM
The interventional cardiology fellowship program at St. Louis University
is a one year program for physicians who have completed Internal
Medicine and General Cardiology training. Requirements include
board certification in Internal Medicine and completion of at least 3
years of training in a Cardiology fellowship including certification for
cardiac catheterization and coronary angiography.
One fellow is accepted each academic year. The fellows
responsibilities include evaluation and care of patients referred for
cardiac catheterization and undergoing interventional procedures and
performance of those procedures with the attending interventional
cardiologists. Fellows will be involved in over 350 procedures including
coronary intervention, structural heart disease, and peripheral
interventions. Fellows will also participate in ongoing clinical trials in
the cardiac catheterization labs and perform a research project for
publication.
The interventional cardiology affiliated hospitals include St. Louis
University Hospital and John Cochran VA Medical Center. Upon
completion of the training, the fellow will have qualifications to perform
coronary and peripheral interventions. Fellows will be board eligible for
the American Board of Internal Medicine, Interventional Cardiology
certifying examination.
St. Louis University School of
Medicine
Division of Cardiology
2016-2017 Interventional Fellowship Training Program
Application Instruction Sheet
Please use this sheet as a “checklist” for application requirements!
I. Please send the following letters of recommendation and have them addressed to
Michael Forsberg, M.D. Director of Fellowship Training in Interventional Cardiology. The
address is the same as listed on the application.
1. Chief of Service or Director during Fellowship.
2. Two other physicians who are qualified to evaluate your ability and qualifications for the
specific fellowship.
3. Copies of official scores from all exams attempted since your matriculation into medical
school.
ABIM
USMLE
FLEX
NBME
4. Curriculum Vitae.
5. Personal Statement.
6. If you are a graduate of a medical school outside the United Stated or Canada,
please send a copy of your ECFMG certificate.
7. Please attach a photo of yourself to the application.
THE DEADLINE FOR RECEIVING YOUR APPLICATION MATERIAL IS
Friday, January 15th
ST. LOUIS UNIVERSITY SCHOOL OF
MEDICINE APPLICATION FOR
INTERVENTIONAL CARDIOLOGY
FELLOWSHIP 2016-2017
Return this application and all necessary documents (January 15th)
To: Michael Forsberg., M.D.
Director, Fellowship Training Interventional Cardiology
St. Louis University Hospital
3635 Vista Ave at Grand Blvd.
DFT13
St. Louis, MO 63110 Attach Recent Photograph Here
Attention: Denise
Bizenberger
Phone: (314) 268-7992
Fax: (314) 268-5410
PERSONAL DATA
Name in Full:
Last First Middle
Home Address:
Street Address
City State Zip Code Country
Telephone:
Home Telephone Number Work Telephone Number
E-mail:
Work Address: Street Address
Cell phone
City State Zip Code Country
Social Security Number: Birthdate: / /
(optional) (optional)
Citizenship:
If not a citizen of the United States please check:
Permanent Resident
J-I Visa
Other:
Please enclose a copy of your immigration visa together with the date and results of the Foreign Medical
Graduate test.
EDUCATION List degrees, honors,
majors, minors:
to College:
(mo/yr) (mo/yr) Name Degree
City State Country
to_
Medical
School:
(mo/yr) (mo/yr) Name Degree
City State Country
to_
Graduate
School:
(mo/yr) (mo/yr) Name Degree
City State Country
POST-GRADUATE MEDICAL TRAINING
to_ Internship:
(mo/yr) (mo/yr) Hospital Name
Type Chief/Department Chairman
to_ Residency:
(mo/yr) (mo/yr) Hospital Name
Type Chief/Department Chairman
to_ Fellowship:
(mo/yr) (mo/yr) Hospital Name
Type Chief/Department Chairman
to_
Present
Position:
(mo/yr) (mo/yr) Hospital Name
Type Chief/Department Chairman
Other Post-Graduate Training:
Post Graduate Research Training:
Previous Research Experience (as a student or house officer):
OFFICIAL SCORES:
List all (post-matriculation) examinations you have taken, scores and dates (ABIM, USMLE, NBME, FLEX, etc.):
EXAM SCORES DATE
ABIM
Internal Medicine
Cardiovascular Disease
USMLE I
USMLE II
USMLE III
FLEX
NBME
Honors, Awards:
List states licensed to practice:
Bibliography: List articles that have been published or accepted for publication in peer review journals
One reprint of each article should be included with the application.
Medical and scientific affiliations:
Applicant Signature: Date:
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Internventional-application - interventional _application

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Completed 6 March 2020

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