Universal Pain Fellowship Application Form PDF Details

The Universal Pain Fellowship Application form serves as a comprehensive tool designed to streamline the application process for candidates aspiring to specialize in pain medicine. This all-encompassing form requires applicants to provide detailed information, including their desired start date, personal and contact information, and specifics about their educational background. It also queries applicants on important matters such as revocations or denials of licenses and privileges, service obligations post-fellowship, and citizenship status. Importantly, the form invites applicants to list their medical training and education, including details about residency, internship, research experiences, and academic achievements from undergraduate and graduate studies. Candidates are encouraged to schedule interviews within specified time frames and are required to submit letters of recommendation, in addition to a Dean's letter, with strict instructions on letterhead and signature requirements. Additionally, applicants have the option to waive or reserve the right to access these letters. The instruction section emphasizes the importance of including a CV and a personal statement to complement the application, highlighting significant experiences, publications, professional affiliations, and community service, alongside clarifying the applicant's professional aspirations and reasons for pursuing a career in pain medicine. Each candidate must affirm the completeness and accuracy of their information by signing the form electronically, underscoring the serious commitment to truthfulness and integrity in the application process. Furthermore, the form provides specific guidelines on the submission process, reiterating the applicant's responsibility to adhere to individual program requirements and deadlines for the submission of supplementary materials.

QuestionAnswer
Form NameUniversal Pain Fellowship Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namespain application form pdf, universal medicine application form print, universal pain fellowship printable, medicine fellowship application form

Form Preview Example

UNIVERSAL PAIN MEDICINE FELLOWSHIP APPLICATION

Desired Start Date(s) (Month/Year)

Name Last

Date of Birth (MM/DD/YY)

First

MD

SSN

PhD

Middle

DO

Other

Address

City, State, ZIP

Home Phone

 

Cell Phone

 

 

 

E-mail

Current Hospital/Insitution

Other Phone

Alternate E-mail

City, State, ZIP

PLEASE COMPLETE THE FOLLOWING CONCERNING ANY REVOCATIONS AND/OR DENIED PRIVILEGES.

Have you ever been denied a license and/or privileges?

If YES, please provide information concerning the incident(s):

Are you required to fulfill any service obligations post-fellowship (i.e. National Health Service Corps, Armed Forces Scholarship, state programs, etc.)?

If YES, please state your service start date and length

Citizenship

United States

Other (specify)

Permanent Contact Name

Visa Status

Address

Phone

USMLE/COMLEX Scores

Step 1

Date

Board Certified Specialities (if applicable)

Step 2

Date

Step 3

Date

Year Certified

Expires

Photo (optional)*

*To add photo: save file to computer, open local copy, click image field above.

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

MEDICAL TRAINING & EDUCATION

 

 

 

Program/Hospital Name, City, State

 

Specialty

 

 

Dates (M/Y-M/Y)

Residency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Program/Hospital Name, City, State

 

 

Type

 

 

Dates (M/Y-M/Y)

 

 

 

 

 

 

 

 

 

 

 

Internship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution Name, City, State

 

 

 

 

Dates (M/Y-M/Y)

Research

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Experience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Research Topic

 

 

 

 

 

 

 

 

 

 

 

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution Name, City, State

 

 

 

 

Dates (M/Y-M/Y)

Research

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Experience

 

 

 

 

 

 

 

 

 

 

 

Research Topic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution Name, City, State

 

Degree

 

 

Dates (M/Y-M/Y)

Medical School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution Name, City, State

 

Degree & Major

 

 

Dates (M/Y-M/Y)

 

 

 

 

 

 

 

 

 

Graduate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institution Name, City, State

 

Degree & Major

 

 

Dates (M/Y-M/Y)

 

 

 

 

 

 

 

 

 

Undergraduate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Undergraduate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Honors/Awards

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
The following general time period is most convenient for me:

INTERVIEW SCHEDULING (please select one)

From:

I am able to schedule an interview on the following specific date(s):

Date:

 

Date:

 

Date:

 

 

 

 

 

I am not available for an interview.

To:

Date:

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

(All letters must be on letterhead with the recommender's signature or e-signature)

Name

 

Title

 

Institution

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please select one:

I hereby waive the right to access the above letters and will so inform the authors.

I hereby reserve the right to access the above letters and will so inform the authors.

By typing your name below you are submitting an e-signature which will act as your signature confirming your understanding and adherence to the following statement:

I have read and I understand the instructions for completing this application. I certify that the information submitted in this application, and in supplemental documents, is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me for this position.

Signature of Applicant

Date

INSTRUCTIONS FOR THE UNIVERSAL APPLICATION FOR PAIN MEDICINE FELLOWSHIP

PLEASE READ CAREFULLY

1.Please include your CV and PERSONAL STATEMENT as separate documents. Your CV should include (but is not limited to) the following:

-Additional research experience

-Publications & contributions (abstracts, manuscripts, peer-reviewed articles, presentations)

-Memberships & Professional/Society Meetings (if applicable)

-Community service work

-Certifications

-Honors

-Licenses, etc.

Your PERSONAL STATEMENT should include your short and long-term professional goals and why you are interested in pursuing a pain medicine fellowship.

2.PLEASE BE SURE TO CHECK WITH INDIVIDUAL PROGRAMS FOR ADDITIONAL APPLICATION REQUIREMENTS AND GUIDELINES.

SUBMITTING THE UNIVERSAL PAIN MEDICINE FELLOWSHIP APPLICATION

Please submit the completed universal application form via e-mail to each program to which you wish to apply. It is the applicant's responsibility to arrange to submit required supplementary materials (transcripts, diplomas, certificates, board scores, etc.) by the designated program's stated deadline.

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Completing part 1 in universal pain fellowship get

2. When the last array of blanks is completed, proceed to enter the suitable information in these - Have you ever been denied a, Are you required to fulfill any, If YES please state your service, Citizenship, United States, Other specify, Visa Status, Permanent Contact Name, Address, Phone, USMLECOMLEX Scores, Step, Step, and Step.

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4. The subsequent part comes next with all of the following blank fields to consider: Residency, Residency, Internship, Research Experience, ProgramHospital Name City State, Specialty, Dates MYMY, HonorsAwards, ProgramHospital Name City State, Type, Dates MYMY, Institution Name City State, Dates MYMY, HonorsAwards, and Research Topic.

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