UNIVERSAL APPLICATION FORM
(revised in 1998)

INSTRUCTIONS - Read Carefully

This application should either be typed or printed legibly in black ink.

The completed application may be copied (except for signature) for distribution to all programs to which you are applying, but each submitted application must be signed and dated by you.

Photograph: Although not compulsory, program directors find photographs of applicants useful in identifying candidates with whom they have spoken during the interviewing process.

Letters of Recommendation: You are requested to submit the names of three of your mentors whom you believe can provide an assessment of your potential for a career in thoracic surgery. One of these should be your General Surgery Program Director. It is your responsibility to ask these individuals for their letters of support and to be certain that they are mailed to the programs to which you are applying.

Application for Thoracic Surgery Residency Beginning in (specify year):

Name:

2x2 photo

Social Security Number:

Home Address:

Work Address:

Home Telephone:

Work Telephone:

Citizenship: U.S. or other (specify):

If not U.S., specify one of the following (permanent; J-1; temporary; H-1):

DEA Certification Number
Expiration Date

CPR Certification Date
Expiration Date

ACLS Certification Date
Expiration Date

Medicare UPIN Number
Thoracic Surgery NRMP No.

EDUCATION

List school/institution, state, dates attended, major/area of study and degree earned

Undergraduate:

Graduate:

Medical School:

Internship:

General Surgery:

Residency:

Other Residency:

Fellowship:

Research Experience:

Application for Thoracic Surgery Residency

American Board of Surgery Status: Eligible (accepted by the Board for examination)

Specify date and certificate number:

Examination Results (list id number, year, numeric score and percentile):

USLME, Step I

USLME, Step II

USLME, Step III

(International Graduates only)

FMGEMS (English Exam - list id number, year, numeric score and percentile):

Surgery In-Training:

ABSITE I
ABSITE II
ABSITE III
ABSITE IV
ABSITE V
Flex: Part I
Flex: Part II

Medical Licensure:
State:
No.:
Date Issued:
Expiration Date:

Honors/Awards:

Publications: (Attach separate page(s ) if necessary)

HEALTH/Ethical Considerations:
Since graduation from Medical School, have you had any mental or physical health problems that would interfere with the practice of medicine?

Have you had any problems with drug or alcohol abuse?

Have you been subject to any disciplinary action in regard to your professional activities?

Have you ever been under investigation by any governmental or other legal body?

Elaborate on a separate sheet of paper any item above to which you have responded in the affirmative.

Letters of Reference Requested From:

1. General Surgery Program Director
Name and Title:
Institution:
Address:

2. Name and Title:
Institution:
Address:

3. Name and Title:
Institution:
Address:

OPTIONAL
Equal Opportunity/Affirmative Action
This institution is committed to a policy of equal opportunity and affirmative action in the appointment process. If you chose to, indicate your self-description by checking the following:

Female or Male

Asian/Pacific Islander
African American/Black
American Indian/Alaskan Native
Hispanic -
(Circle one: Mexican American, Puerto Rican, Cuban, Mexican, Central American, South American)
European American/White
Other

Personal Statement: (In no more than two single-spaced typewritten pages, discuss your motivation for pursuing a career in Thoracic Surgery, your professional goals at this time, and any aspects of your background or past achievements that have been particularly important in your life. You may also describe significant research or work experience, personal interests, or activities which you feel are pertinent. Any unusual interruption in your medical education should also be explained in this personal statement.)

I certify that the information submitted on this application form is correct to the best of my knowledge, and I understand that false or missing data may disqualify me from this position.

Signature/Date