Spreadsheet: 014a81fc-703b-4763-b8d9-92ef37f96eaf
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Division of Cardiovascular Medicine | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5
Oregon Health & Science University
Application for Heart Failure Fellowship Program
Name:   First: |  | Middle Initial: | Last:
Previous last name, if any:
[NAME]:
Gender:
Birth date:
Birth place (City/State/Country):
SSN:
Citizenship:
[NAME] (if applicable):
ECFMG Certification: | Certification Date (mm/yyyy): |  |  | Expiration date: (mm/yyyy):
Race:
Ethnicity:
Contact Address: |  | Permanent Mailing Address:
Preferred Phone #:
Alternate Phone #:
Mobile #:
Pager #:
Fax #:
Medical School:
Institution & Location: |  | Dates Attended: | Degree: | Graduation Date (mm/yyyy):
Graduate School:
Institution & Location: |  | Field of Study: | Degree: | From (mm/yyyy): | To (mm/yyyy):
Internal Medicine Residency:
Institution & Location: |  | Program Director |  | From (mm/yyyy): | To (mm/yyyy):
Cardiovascular Fellowship:
Institution & Location: |  | Program Director |  | From (mm/yyyy): | To (mm/yyyy):
Other Fellowships:?
Institution & Location: |  | Program Director |  | From (mm/yyyy): | To (mm/yyyy):
Professional Experience:
Experience: | Organization: | Position: | Dates: | [NAME]: | Supervisor:
Research:
Experience: | Organization: | Position: | Dates: | [NAME]: | Supervisor:
 | Description:
Experience: | Organization: | Position: | Dates: | [NAME]: | Supervisor:
 | Description:
Experience: | Organization: | Position: | Dates: | [NAME]: | Supervisor:
 | Description:
Military Obligation/ Deferment? |  | Years: |  | Branch:
Other service oblication? | Yes ___________ | No  ___________ | Description:
[NAME]? | Yes ___________ | No  ___________ | Reason:
Limitations? | Yes ___________ | No  ___________ | Description:
Examinations
Examination: | Date taken (mm/yyyy) | Scores |  | Status (pass/fail)
USMLE Step 1
USMLE Step 2 CK          (Clinical Knowledge)
USMLE Step 2 CS (Clinical Skills)
USMLE Step 2
USMLE Step 2 CK          (Clinical Knowledge)
USMLE Step 2 CS (Clinical Skills)
USMLE Step 3
State Medical Licenses
Type (Temorary/Limited, Full/Unrestricted) | License Number | State |  | Effective Date (mm/yyyy) | Expiration Date (mm/yyyy)
ACLS: | Yes _____   No_____ | Effective Date: (mm/yyyy) |  | Expiration Date: (mm/yyyy)
PALS: | Yes _____   No_____ | Effective Date: (mm/yyyy) |  | Expiration Date: (mm/yyyy)
DEA Reg. #: |  | Effective Date: (mm/yyyy) |  | Expiration Date: (mm/yyyy)
NPI #: |  | Effective Date: (mm/yyyy) |  | Expiration Date: (mm/yyyy)
Board Certification: | Yes _____   No_____ | Effective Date: (mm/yyyy) |  | Expiration Date: (mm/yyyy)
Medical [NAME]? | Yes _____   No_____ | Reason:
Ever named in a malpractice suit? | Yes _____   No_____ | Reason:
Membership in Honorary/Professional Societies:
Publications: (You may attach as a separate document or "refer to [NAME]")
Hobbies/Interests:
[NAME] (other than English):
Other Awards/Accomplishments:
Certification: | I certify that the information contained in this application is complete and accurate to the best of my knowledge.  I understand that any false or missing information may disqualify me from consideration for a fellowship position, or if employed, may constitute cause for termination from the fellowship program.
Certified by: |  |  |  | Date:
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