Application For Residency Form – Fill Out and Use This PDF

UNIVERSAL APPLICATION

FOR

RESIDENCY

The Universal Application for Residency was developed by the Association of American Medical Colleges (AAMC) in collaboration with hundreds of residency program directors. It is designed to provide information generally required for consideration by program directors and to facilitate the residency application process. All programs are urged to accept this application in lieu of requiring the submission of a unique form and many programs have adopted this form as the application for their program. Applicants are encouraged to submit copies to all programs in which they would like to be considered.

Developed

by the

ASSOCIATION OF AMERICAN MEDICAL COLLEGES

Distributed

by the

NATIONAL RESIDENT MATCHING PROGRAM

2501 M Street, NW, Suite 1

Washington, DC 20037-1307

APPLICATION FOR RESIDENCY - PAGE THREE

15.

NAME

(LAST)

(FIRST)

(MIDDLE)

16.

SOCIAL SECURITY NUMBER

17. ECFMG Registration (if applicable)

-

-

18.

SHALL PARTICIPATE IN NRMP MATCH

19. NRMP CODE (enter "pending" if unknown)

YES

NO

ATTACH RECENT

20.

PRESENT ADDRESS

(STREET)

PHOTOGRAPH

(CITY)

(STATE)

(ZIP)

OPTIONAL

(SEE INSTRUCTIONS)

PRESENT PHONE NOS.

DAY (

)

EVENING (

)

21.

NUMBER OF DEPENDENTS

22. VISA STATUS (IF APPLICABLE)

PERMANENT

J-1

TEMPORARY - SPECIFY:

23.

CITIZENSHIP

OTHER

H-1

U.S.

24.

PERMANENT ADDRESS:

C/O (NAME OF PERSON THROUGH WHOM I CAN ALWAYS BE CONTACTED)

(STREET)

( )

I plan to take the examinations checked below before I begin the Graduate Medical Education program for which I am now applying:

I have already passed the examinations checked below on the dates indicated:

FLEX:

(DATE)

(STATE(s) of licensure)

LIST ANY ADDITIONAL EXAMINATIONS PASSED (FMGEMS, DAY 1; FMGEMS, DAY 2; VQE, DAY 1; VQE, DAY 2; ECFMG MEDICAL SCIENCE EXAM):

INTERVIEW SCHEDULING

27.

THE FOLLOWING GENERAL TIME PERIOD IS MOST CONVENIENT FOR ME:

FROM:

TO:

I AM ABLE TO SCHEDULE AN INTERVIEW ON THE FOLLOWING SPECIFIC DATE(s):

(DATE)

(DATE)

(DATE)

(DATE)

I AM NOT ABLE TO COME FOR AN INTERVIEW

I have read and I understand the instructions for the completion of this application. I certify that the information submitted on these application materials is complete and correct to the best of my knowledge: I understand that any false or missing information may disqualify me for this position.

28.

SIGNATURE OF APPLICANT:

DATE:

NOTE: THE SIGNATURE AND DATE ON EACH APPLICATION MUST BE ORIGINAL.

APPLICATION FOR RESIDENCY - PAGE FOUR

LETTERS OF REFERENCE, IN ADDITION TO THE DEAN'S LETTER, HAVE BEEN REQUESTED FROM THE FOLLOWING INDIVIDUALS:

29.A. NAME AND TITLE

INSTITUTION

ADDRESS

B.NAME AND TITLE

INSTITUTION

ADDRESS

C.NAME AND TITLE

INSTITUTION

ADDRESS

D.NAME AND TITLE

INSTITUTION

ADDRESS

SIGNATURE

DATE

NAME OF APPLICANT - TYPE OR PRINT

NOTE: THE SIGNATURE AND DATE ON THIS STATEMENT MUST BE ORIGINAL.

No. N-1020 4/97

COPYRIGHT © 1997 BY THE NATIONAL RESIDENT MATCHING PROGRAM

INSTRUCTIONS FOR THE UNIV ERSA L A PPLICA TION FOR RESIDENCY - PLEA SE REA D CA REFULLY

USING THE UNIV ERSA L A PPLICA TION TO A PPLY TO M ULTIPLE PROGRA M S

Usage of the Universal Application is not dependent upon whether a program participates in the NRMP. A blank copy of the Universal Application may be completed in its entirety for each program; or, an applicant may elect to:

!Remove this instruction page at the perforation.

!Complete Page 1, with the exception of Item 3 (Program Description), Item 4 (Name of Hospital), and Item 5 (City/State) and enter the missing information specific to each program on copies; and,

!Complete Page 2 and copy; and,

!Complete Pages 3 and 4, with the exception of Signatures in Items 28 and 30 (these signatures must be original on all copies); and,

!Staple the copied pages together in the upper left corner for distribution to individual programs, ensuring that copies are clear

,legible and sequential.

It is recommended that you keep on file copies in the event you want to submit additional applications at a later date.

COM PLETING THE UNIV ERSA L A PPLICA TION FOR RESIDENCY

Please type or print legibly in black ink.

Electives Completed/Planned (Page 1, Item 9): List all electives completed and all senior electives planned. Planned electives should be designated by a "P" following the course title [i.e., Cardiology (P)].

Honors/Awards (Page 1, Item 10): List all honors/awards, including membership in honor societies such as AOA. Specify the basis for any special recognition (i.e., academic performance, special accomplishments, leadership, research, community service, etc.)

Personal Statement (Item 13, Page 2): The Personal Statement provides you with the opportunity to communicate your professional interests and achievements with regard to research experience and training, special projects, and professional accomplishments. Bibliographic references should be provided for all published papers. Program Directors are also interested in your future plans as defined by your specialty goal and the number of years you intend to devote to graduate medical education.

You may also wish to describe your personal interests, activities, and circumstances. As transcripts of your academic accomplishments are most likely to be required, any interruption in your medical education should be explained in the Personal Statement.

Permanent Address and Telephone Number (Items 24, Page 3): Enter the name, address, and telephone number of an individual through whom you can always be contacted (i.e, parent, relative, close friend, etc.).

Interview Scheduling (Item 27, Page 3): Indicate the specific date(s) or general time period that you are available for interviews.

Photograph: Most program directors request a photograph in order to associate a face with the "paper work". If you do not submit one at this time, you should be prepared to provide one when you are interviewed.

References (Item 29, Page 4): Virtually all hospital programs require the Dean's Letter for U.S. seniors as a standard reference. Non-U.S. seniors should attempt to provide evaluations from faculty members at their medical degree-granting institution. Most programs require a minimum of three additional evaluations. References should be from faculty members or physicians who are familiar with your credentials and are in a position to comment on your suitability for the position you seek.

COM PLETING THE PROGRA M DESIGNA TION A ND A CKNOW LEDGEM ENT CA RDS

Program Designation Card: Side 1 - Enter the indicated information and designate the institution (hospital) and program description to which you are applying. Information on this card should correspond exactly to information listed in Items 3, 4, and 5 of this application. Be sure to designate the year in which you expect to begin your residency.

Acknowledgement Card: Enter your name and current mailing address. This card will be returned to you by the program to acknowledge receipt of your application materials. Sufficient postage should be affixed for mailing.

Do not separate these two cards. You should complete a Program Designation Card and an Acknowledgement Card for each application that you submit. Additional cards can be purchased from the NRMP or you may use self-addressed, stamped postcards.

SUBM ITTING THE UNIV ERSA L A PPLICA TION FOR RESIDENCY

You should submit all four pages of the Universal Application for Residency, with original signatures, to each program to which you wish to apply. Attach the Program Designation/Acknowledgement Cards to the upper left corner of Page 1 of the Universal Application and fold. Do not separate cards. It is the applicant's responsibility to arrange to submit required supplementary materials (transcripts, letters of evaluation, etc.) by the designated program's stated deadline.

DO NOT RETURN THE UNIVERSAL APPLICATION TO THE NRMP

No. N-1020 4/97

COPYRIGHT © 1997 BY THE NATIONAL RESIDENT MATCHING PROGRAM