VIR Radiology Fellowship APPLICATION FORM - UAMS Medical ...

VIR Radiology FellowshipAPPLICATION FORMReturn completed form with a copy of your CV to the fellowship director at either address byApril 1. Letters of recommendation should be mailed to the program director.Linda A. Deloney, EdDDepartment of RadiologyUniversity of Arkansas for Medical Sciences4301 West Markham, #556Little Rock, AR 72205deloneylindaa@uams.eduNAME ____________________________________________________ _______________________Last First M.I. DegreeCURRENT CONTACT INFORMATIONPreferred E-mail Address: ___________________________________________________________Street Address:____________________________________________________________________City: ___________________________________ Country: ________________________________State/Province: __________________________ Zip Code: _______________________________Home Telephone: _______________ Work Telephone: ___________ Pager: _________________CITIZENSHIP/STATUS _______________________SSN/SIN _________________________________BIRTH DATE_____________BIRTHPLACE ___________ [This information is required upon acceptance.]EDUCATION Dates DegreeCollege ____________________________________________ ______ to ______ _________Medical ______________________________________________ ______ to ______ _________Other _____________________________________________ ______ to ______ _________Internship _____________________________________________ ______ to ______ _________RESIDENCY PROGRAMInstitution____________________________________________________________________________Field __________________________________________ Dates ____________________________Institution____________________________________________________________________________Field __________________________________________ Dates ____________________________Other _______________________________________________________________________________PRESENT EMPLOYMENT _________________________________________________________________HOSPITAL APPOINTMENTS _______________________________________________________________OVERALL CAREER GOALS: [practice, academic, etc.] __________________________________________________________________________________________________________________________________________________________________________________________________________________SPECIAL AREAS OF INTEREST: [CVNM, GI, etc.] __________________________________________________________________________________________________________________________________RESEARCH INTERESTS: _____________________________________________________________________________________________________________________________________________________

MEDICAL LICENSURE [State/Year] ______________________________________________________Has your medical license ever been suspended/revoked/voluntarily terminated? Yes ______ No _______If yes, provide reason ___________________________________________________________________Have you ever been named in a malpractice case? Yes ________ No ________If yes, provide reason ___________________________________________________________________Is there anything in your past history that would limit your ability to be licensed or to receive hospitalprivileges? Yes ________ No ________If yes, provide reason ___________________________________________________________________Have you ever been convicted of a felony? Yes ________ No ________If yes, provide reason ___________________________________________________________________[The applicant may be required to provide additional information and be required to submit for a criminalbackground check.]ECFMG STATUS [If the applicant is an international medical graduate, we require documentation ofcurrent visa status and a copy of ECFMG certificate.] __________________________________________ACLS CERTIFIED? Yes ________ No_______ [Proof of certification will be required upon acceptance.]AMERICAN BOARD OF RADIOLOGY EXAMS [Provide dates taken and results. If not certified, provide dateyou intend to take.]Physics: _________________ Written: ________________________ Oral: _______________________REFERENCES [Please list the names and institutions of 3 physicians who will be mailing letters for you.]1] _______________________________________________________________________________2] _______________________________________________________________________________3] _______________________________________________________________________________ARE YOU WILLING TO COME FOR AN INTERVIEW?_______ WHEN? ______________________________I hereby declare that the information contained within this application is true and accurate. I understandthat supplying misinformation to the questions above is grounds for disciplinary action, includingimmediate dismissal from the program.Date__________________________ [Signed]_______________________________________________