Otologic Fellowship Program

THE OTOLOGY GROUP OF VANDERBILT

7209 Medical Center East-South Tower

1215 21st Avenue South

Nashville, Tennessee 37232-8605

Attn: Karen Olayinka

Telephone: 615.343.6972 Facsimile: 615.875.5559

Application Deadline is June 3, 2013

Application For Fellowship Beginning July 1, 2014

Please complete and attach all information requested, utilizing “N/A” as appropriate. Applications containing blanks, and/or missing attachments, will not be considered. Thanks!

General Information:

Name

Address

City State/Zip

Phone: [Work] [Home] [Cell]

E-Mail Address:

Citizenship: Visa Type? Social Security #

Present Activity:

Resident: Program

Military: Branch/Duty Station

____ Reserve or National Guard Status

Are you obligated, through a health professions loan, for military obligation?

Academic/Private Practice: Group Name/Location

Other (specify):

Licensure/Certification:

ACLS:Exp. Date:

PALS:Exp. Date:

BLS:Exp. Date:

DEA Reg #:Exp. Date:

Board Certification:Name:Recert. Date:

State Medical License(s):*Type:Number:State:Exp. Date:

*A TN state medical license is not required to practice as a fellow in our Program. Training waiver applies.

Have you been party to any malpractice liability claims, suits, and/or settlements?

Yes ___ No ___ (If yes, please attach a summary)

CRIMINAL RECORD: Have you ever been convicted of a crime, other than a minor traffic violation? If so, please explain:

REFERENCES: Please submit names and addresses of three physicians who are acquainted with your academic and/or professional experience and your personal character:

(1)

(2)

(3)

Supplemental Information Required:

1. Photograph
2. Two letters of recommendation, one of which is from the Program Director of your residency training program. You may submit more than two letters, if you desire; however, only two are required.Please have these mailed to us directly.Do not include as part of application.
3. A current Curriculum vitae per normal format and including:
4. Colleges and Universities Attended (include dates and degrees)
5. Medical School, Dates of Attendance, Date of Degree(s)
6. Postgraduate Training, other than above (Fellowship, Courses in Basic Science, Summer

Research,etc. Include Location, Type of Activity, and Dates)

• Membership in Honorary/Professional Societies
• Membership in Scientific and/or Professional Organizations
• Honors/Awards
• Work/Research Experience
• Publications
• Language Fluency
• Hobbies and Interests

1. Copy of medical school transcript.
2. Proof of ECFMG certification, if applicable.

*ECFMG certification is required for IMGs who come to Vanderbilt for clinical training. ECFMG is an authorized agency to sponsor a J-1 visa. For the purpose of residency training, Vanderbilt accepts J-1 visas only.*

1. Personal Statement including career objectives.

How did you hear about our Fellowship Program?

I certify that the information listed above, and on the attached Curriculum vitae, is correct.

Signature

(Full Legal Signature)

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