ࡱ> - !bjbj=@=@ 46_*d_*d!$<<tQQQQQ,,,$f"V!,,QQ"QQQvrk^ 0<"Kb"",h&TzQ,,,j,,,<",,,,,,,,, :  Please attach recent photo I hereby apply for appointment as a Graduate Medical Trainee at University Hospitals Case Medical Center of Cleveland, Ohio for _____________________________months, beginning ___________________________ PLEASE (") APPOINTMENT DESIRED Neurology Residency ( ) Neuromuscular Fellowship ( ) Neurovascular Fellowship ( ) Neurobehavioral Fellowship ( ) Neurocritical Care Fellowship ( ) Other: _____________________________ Full Name: _______________________________ M.D. ____ M.B.B.S. ______ D.D.S. ______ D.O. ____ M.B.B. Ch. ____ D.M.D. _____ DEMOGRAPHICS Present Address: ________________________________________________________________ City: ___________________State: __________ Zip ________ Country: ________________ Telephone: _____________________________ Beeper #: ___________________________ E-Mail Address: _________________________ Fax #: ______________________________ Permanent Address: _____________________________________________________________ City: ___________________State: __________ Zip ________ Country: ________________ Other: Place of Birth: ______________ Date of Birth: ___________ Married: ____ Single: _____ Citizen of: _________________________ U.S. Social Security #: _______________________ MEDICAL LICENSE U.S. Unrestricted Medical License (attach copy): Graduate medical Training License (attach copy): State: ____________________No. _________________ State: ______________________ No: __________ State: ____________________No. _________________ State: ______________________ No: __________ U.S. Licensing Exams passed (attach copy of scores for each exam): ECFMG English: ________TOEFL _____ Clinical Skills Assessment: ___ LMCC ____ FLEX ______ State Board ________FLEX 1______FLEX II ______NBME 1 ______ NBME III _____ USMLE 1 ______ USMLE 2 _______ USMLE 3 ______ Medical License/International Medical Graduates: (attach copies of each document) ECFMG Certificate No. _______________ Type of Visa _______________ Hold _______ Needed _______ MEDICAL EDUCATION AND TRAINING Medical Education: Institution: ____________________________________________________________________________________ From :______________ To:________________ Degree:____________________________________ Hospital Training: (Do not list rotations in medical school): Hospital Location From To Degree ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Post Graduate Education: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Special Training (not already listed, such as assistantships, summer work, extra curricular activities practice, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Board Certification: Year Specialty Name of Board Country of Issuing Board ____________________________________________________________________________________________ ____________________________________________________________________________________________ Publications & Grants ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ REFERENCES: Communications concerning professional ability and personal qualifications must be sent under separate cover directly to Kristin Stacy, Department of Neurology at University Hospitals Case Medical Center from at least three (3) physicians, preferably under whom you served or training. Letters of recommendation must be requested by the applicant. 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