Fillable Standardized Application for Pathology Fellowships Department of Pathology (Ohio State University, Columbus)

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Standardized Application for Pathology Fellowships Department of Pathology (Ohio State University, Columbus)

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The Standardized Application for Pathology Fellowships Department of Pathology (Ohio State University, Columbus) form is 6 pages long and contains:

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  • 10 check-boxes
  • 128 other fields

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File type: PDF

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0726200708
Standardized Application for Pathology Fellowships
Department of Pathology
Applicant Name
Last name
First
Middle
Fellowship Type
This application is being made for a fellowship in (please check one):
Blood banking/Transfusion medicine Gastrointestinal pathology
Cytopathology Hematopathology
Dermatopathology Renal pathology
Training period for which applying:
Start date
Finish date
Personal Data
Other names used:
Present Address
Street
City
ZIP / Postal code
Permanent Address
Street
City
ZIP / Postal code
Telephone
Home
Work
Mobile
Fax
E-mail:
Date of birth: Place of birth:
Citizenship:
If not a U.S. citizen, type of Visa:
Please affix a recent passport-
sized photo here.
If submitting electronically,
include a recent passport-style
photo in .JPG format with the
application.
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Education
(Mo/Yr)
(Mo/Yr)
(Undergraduate School)
(Major)
(Degree)
to
(Mo/Yr)
(Mo/Yr)
(Graduate School, if applicable)
(Degree)
to
(Mo/Yr)
(Mo/Yr)
(Medical School)
(Degree)
to
(Mo/Yr)
(Mo/Yr)
(Residency)
(AP, CP, AP/CP, other)
to
(Mo/Yr)
(Mo/Yr)
(Other GME, if applicable)
Area of training
to
(Mo/Yr)
(Mo/Yr)
(Other GME, if applicable)
Area of training
to
Other Experience
In chronological order, list other educational experiences, jobs, military service or training that is not accounted for above.
(Mo/Yr)
(Mo/Yr)
to
(Mo/Yr)
(Mo/Yr)
to
(Mo/Yr)
(Mo/Yr)
to
National Boards
Please indicate national board examination dates and results received. Send copies of results.
USMLE Step 1
USMLE Step 2
USMLE Step 3
Date passed
Score (required)
Date passed
Score (required)
Date passed
Score (required)
COMLEX Level 1
COMLEX Level 2
COMLEX Level 3
Date passed
Score (required)
Date passed
Score (required)
Date passed
Score (required)
Medical Licensure
Please list any states in which you hold a license to practice medicine. Please provide a license number. If an application is
pending in a state, please write “pending.”
(State)
(Date Issued)
(Medical License Number)
(Active?)
Yes No
(State #2)
(Date Issued)
(Medical License Number)
(Active?)
Yes No
(State #3)
(Date Issued)
(Medical License Number)
(Active?)
Yes No
Have you ever been reprimanded, or had your license suspended or
revoked in any of these states?
Yes (If so, please explain in an attached sheet.)
No
Have you ever been named in (and/or had a judgment against you) in
a medical malpractice legal suit?
Yes (If so, please explain in an attached sheet.)
No
Board Certification
Please indicate any areas of board certification.
Board
Area of Certification
Date of Certification
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Honors, Awards, Publications, Presentations, Memberships, Leadership/Research Experience
Please list on attached application forms or include this information in your CV.
Letters of Recommendation and/or References
Please list the individuals who will write your letters of recommendation. At least three are required and one must be from
Residency Program Director.
Reference #1
Name
Title
Institution
Address
City
State
ZIP / Postal Code
Telephone
Email
Reference #2
Name
Title
Institution
Address
City
State
ZIP / Postal Code
Telephone
Email
Reference #3
Name
Title
Institution
Address
City
State
ZIP / Postal Code
Telephone
Email
Reference #4 (optional)
Name
Title
Institution
Address
City
State
ZIP / Postal Code
Telephone
Email
Signature (may omit if submitting electronically)
I hereby certify that all of the information on this application is accurate, complete, and current to the best of my knowledge, and that this
application is being made for serious consideration of training in the Pathology Fellowship indicated. I understand that accepting more than
one fellowship position constitutes a violation of professional ethics and may result in the forfeiture of all positions.
Signature
Date
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Honors and Awards (if explicitly listed on CV, include highlights here with reference to location on CV)
5
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Publications and Presentations (if explicitly listed on CV, include highlights here with reference to location on CV)
6
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Memberships and Leadership/Research Experience
(if explicitly listed on CV, include highlights here with reference to
location on CV)
7
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Application Packet Checklist
Completed Standardized Fellowship Application Form with Signature
Copies of USMLE or COMLEX scores
Updated Curriculum Vitae (CV)
Included cover letter and/or personal statement
Included photo (optional)
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Standardized Application for Pathology Fellowships Department of Pathology (Ohio State University, Columbus)

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Completed 26 February 2021

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