APPLICATION FOR POSTDOCTORAL FELLOWSHIP IN PEDIATRIC HOSPITAL MEDICINE (PHM) UT SOUTHWESTERN AUSTIN PEDITARICS, AUSTIN TX (Applicant’s last name) (First name) (Middle initial) Date and place of birth Mailing address: (Street) (City) (ZIP code) Telephone numbers where you can be reached during daytime hours: Home / Cell ( ) E-mail Office ( ) Non-work, personal e-mail _________________________ U.S. Citizenship (please circle one): Yes / No (U.S. Citizenship/Green Card required. We are unable to accept candidates with an H1b or J Visa.) College and Degree: Medical School: Internship/ Residency Program: Additional medical training / experience since medical school: Special honors / awards Additional pertinent skills or experience: Scientific publications: Do you currently have an active medical license? Yes / No If yes, enter information: License number: State: Are you board eligible or certifiable in pediatrics? USMLE/NBOME Scores: Part 1 Yes / No Part 2 Part 3 If the answer to any of the next five questions is yes, please attach a letter or explanation for each instance. 1. Have you ever had any disciplinary action taken against you? Yes / No 2. Have you ever had your license revoked, stayed or curtailed? Yes / No 3. Have you ever had any malpractice action taken against you? Yes / No 4. If so, have you entered into any settlements arising from such action? Yes / No 5. Have any insurance claims been paid out on your behalf? Yes / No Ask a minimum of three individuals to prepare letters of recommendation on your behalf. The letters of recommendation should comment on your professional background, achievements, and potential. They should submit their letters to the Pediatric Hospital Medicine Fellowship Director. For instructions, please refer to the last section on this application form, “APPLICATION PACKAGE – WHAT AND HOW TO SUBMIT.” 2 Please list the names and addresses of your references in the following table: Name of Reference (three references required) Address 1. 2. 3. 4. I hereby certify that the information in my application package (application form, narrative statement, CV) is complete and accurate. I understand that misrepresentation of any portion of this application will be cause for cancellation of the fellowship. (Applicant’s signature) (Date) APPLICATION PACKAGE – WHAT AND HOW TO SUBMIT: Application package includes: • Application form • Applicant’s Personal Statement • CV • 3 letters of recommendation (please note: your referees should submit these directly to us using any of the methods below) Submit by one of the following methods: Via email: Mark Shen, MD, [email protected] - PHM Fellowship Director Michael Narvaez [email protected] - PHM Fellowship Coordinator Via fax: (512-324-0786) to the attention of Mary Matus Via mail: Michael Narvaez - PHM Fellowship Coordinator Dell Children’s Medical Center 4900 Mueller Blvd, Ste. 3S.066C Austin, Texas Questions? (512)324-0165 Mark Shen, MD, PHM Fellowship Director Michael Narvaez, PHM Fellowship Coordinator 3