Applicant
Contact Address
Last Name (MD, DO)______________________First Name_______________________
County of Citizenship______________________________________________________
Street___________________________City_________________State____Zip_________
Country________________Phone________________Email______________Fax______
Education and Training
Undergraduate Education
Institution, City, State, Country______________________________________________
Dates Attended___________________________________________________________
Degree__________________________________________________________________
Institution, City, State, Country______________________________________________
Dates Attended___________________________________________________________
Degree__________________________________________________________________
Medical School
Institution, City, State (Country)_____________________________________________
Dates Attended___________________________________________________________
Degree__________________________________________________________________
Institution, City, State (Country)_____________________________________________
Dates Attended___________________________________________________________
Degree__________________________________________________________________
Internship/Residency
Institution, City, State (Country)_____________________________________________
Dates Attended___________________________________________________________
Specialty________________________________________________________________
Institution, City, State (Country)_____________________________________________
Dates Attended___________________________________________________________
Specialty________________________________________________________________
Fellowship
Institution, City, State (Country)_____________________________________________
Dated Attended___________________________________________________________
Specialty________________________________________________________________
Other Graduate Education
Institution, City, State (Country)_____________________________________________
Dates Attended___________________________________________________________
Field of Study, Degree_____________________________________________________
Licensing and Certification
Examinations
USMLE - Step 1 (score)_____________________ Date__________________________
USMLE - Step 2 CK (score)__________________ Date__________________________
USMLE - Step 2 CS (score-if taken)____________ Date__________________________
ECFMG
Are you certified by the ECFMG? N_____Y______ Number______________________
Medical Licenses
Certificate Number_________________ Valid Dates_____________________________
Issuing Agency
Certificate Number_________________ Valid Dates_____________________________
Issuing Agency
Emergency Medicine/Pediatric Emergency Medicine Board Eligibility/Certification
Yes______________ Date__________________________________________________
No_______________ Please explain __________________________________________
CV
Include awards, honors, publications, and research. List your international work, volunteer, and educational experiences. Include specifics of your involvement and dates.
Personal Statement
(500 words)
Why does global medicine interest you?
What specific areas interest you?
What do you hope to accomplish during a Global Health Emergency Medicine Fellowship?
