P. O. Box 9906
Fayetteville, NC 28311-9906

PAACSResidency Application

(Ethiopia & Egypt)

(Instructions: Move from gray blank to blank using the tab key. If there is a box, type in “x” to signify the correct answer. If there is a rectangle, then type your answer in that rectangle.)

Section I:GENERAL INFORMATION

Your Full Name: Date of Birth:

(SURNAME (Grandfather’s), First Name, Middle (Father’s), Other)

Name you go by: Gender/Sex: Male Female
Nationality: Date of Marriage:
Spouse’s Name: Spouse’s Date of Birth:
List the names, date of birth, and ages of your own children under the age of 18. If the children were not born to you or your spouse, please check if legally adopted.

1. Date of Birth Age Adopted

2. Date of Birth Age Adopted

3. Date of Birth Age Adopted

4. Date of Birth Age Adopted

5. Date of Birth Age Adopted

Your Current Mailingor StreetAddress:
One or several phone numbers when we can reach you (include country code):

Your current e-mail address:

Your religion:

Section II: ACADEMIC HISTORY: Please list, in order, the secondary schools and universities you have attended:

Dates School or University Name and AddressDiploma Received

1. From to

2. From to

3. From to

4. From to

5. From to

6. From to

7. From to

Describe any formal medical training you received after graduating from medical school:

DatesHospital Name and Address Certification

1. From to

2. From to

3. From to

4. From to

List the places you have worked since graduation:

Dates Name and AddressPosition Held

1. From to

2. From to

3. From to

4. From to

Do you have any obligations to any organization (hospital, a government, church, military, mission agency, etc.) that you are required to complete either currently or at some date in the future? Yes No. If you answered yes, please provide a description of any obligation. .

Section III: On a separate page, please write out the answers to the following questions in detail:

  1. Why did you choose to go into medicine?
  2. Why do you want to become a surgeon?
  3. What attributes and abilities do you have that you believe will help you become a surgeon?
  4. How do you plan to handle the rigors of five years of surgery residency training?
  5. What do you want to do after you finish your training in general surgery?
  6. Why are you interested in joining the PAACS program?

Section IV: REFERENCES - Provide the names and e-mail addresses and/or telephone numbers of two people that we can contact who can tell us something about you and state their relationship to you (supervisor, friend, professional colleague, etc.):

Name RelationshipE-mail AddressPhone Number

1.

2.

Answer “Yes” or “No” to the following question:

Yes No I have asked my hospital, church, or other institution to financially support me during my surgical training. Their response was

Section IV: YOUR ACCEPTANCE OF THE FOLLOWING POLICIES AND PROCEDURES

By signing this application, I accept the following policies of PAACS Training Programs:

  1. Each year residents must prepare and give formal oral presentations or written case reports at regular intervals. Research projects may also be required.
  2. Residents will be required to first-assist or perform with supervision a minimum of 300 operations a year and will fill out and turn in to their program director a yearly record of operations.
  3. Residents will take a comprehensive examination in general surgery each year that is prepared by the PAACS. If a resident does not pass, the program director will not be obliged to advance the resident to the next level of training. If the Program Director does not believe that a resident’s effort or skill justifies repeating the year, or if the Program Director finds that a resident is insubordinate or irresponsible, the Program Director is under no obligation to keep the resident in the program.
  4. Residents will receive PAACS certification only if they complete all of the requirements of the training program. If a resident drops out after completing only part of the surgical training program or does not pass the final examination at the end of the 5th year, the Program Director will give the resident a certificate of training from PAACS stating that the resident completed a certain number of years of formal surgical training.
  5. All residents must arrange for financial support during their training. Regardless of the source of a resident’s financial support, all first-year residents will receive the same stipend month as a training salary. The amount of the stipend will be set by the hospital and the Program Director, based on the local cost-of-living. The stipend will increase by 5% for each year of training. PAACS may adjust the amount of the stipend as needed, in response to inflation or deflation. Applicants accepted into the program who do not have outside financial support may apply to PAACS for financial support.
  6. Residents who receive financial aid from PAACSwill be asked by PAACS after graduation to serve full-time as practicing surgeons at hospitals approved by PAACS, and for the number of years that residents received financial support from PAACS. Selection of hospitals where graduates may serve out their obligations to PAACS will be selected through a collaborative process involving the graduate, the Program Director, and the leadership of PAACS.
  7. Residents accepted to train with PAACS may not be government employees. If they were employed by the government prior to their acceptance they must include with their application written proof that they have resigned and are no longer considered by their government to be an employee of the State.
  8. The hospital where a resident trains will provide furnished housing, or its financial equivalent, regardless of the source of a resident’s financial support.
  9. Ifa resident is sponsored by his or her family or by an agency other than PAACS the resident will receive the same level of financial support as the other PAACS residents at that level.
  10. Residents are not be permitted to receive direct payment from patients for services, nor is the hospital permitted to pay residents for their services. The monthly stipend will cover scheduled call for nights, weekends and holidays.Residents may not work at hospitals or clinics outside of the hospital where they train unless it is scheduled by the Program Director to improve their training experience.
  11. Residents who are married or who marry during their training may not live apart for more than one year.
  12. Residents must participate in all aspects of the PAACS training program, including extra-mural activities designed to increase their mental, spiritual and emotional health, team-building skills, and relational skills.
  13. Residents must not pursue any outside university-based courses during their training without their Program Director’s written approval.
  14. Failure to provide accurate, complete, and pertinent information requested during the application process may lead to dismissal from the program orrejection of the application.
  15. Residents are responsible for moving their family both to and from the place of training.
  16. Residents may be required to maintain active licensure in both their home country and their country of training.

Please accept my application to become a surgery resident in general surgery with PAACS. I hereby certify that I am in good health and that the statements in the Health Certificate Form I completed are true. I agree to all the terms and conditions stated herein and hereby certify that all information I have provided is correct to the best of my knowledge and belief.

Your Printed Name:

Date Application completed:

ADDITIONAL REQUIREMENTS

Your application must include the following to be complete:

  • A copy of your birth certificate
  • A copy of your current passport
  • If married, a copy of your marriage license
  • A completed PAACS Health Certificate
  • A copy of your medical diploma
  • A copy of your medical license
  • Transcripts from Medical School, Post Graduate, Master Exam
  • A completed PAACS Recommendation Form from a character reference
  • A completed PAACS Recommendation Form from a medical colleague
  • A letter of reference from your present supervisor
  • A good quality, digital color photograph

You are responsible to translateall documentswhich are not in English into English, andto have them notarized.

All required forms and documents must be submitted before September 15.

Once the above information is completed, you will be notified by e-mail of the status of your application and scheduled for one or more interviews with the PAACS faculty. Following your interview, the decision of the PAACS faculty will be final and is not subject to appeal.

Please e-mail this application and scans of all requested documents to: .

The Pan-African Academy of Christian Surgeons (PAACS)

P. O. Box 9906

Fayetteville, NC 28311-9906

For Applicant’s Use Only

Please keep a list of dates as you e-mail documents to PAACS. The deadline for having all of your information in to PAACS isSeptember 15. You are strongly encouraged not to wait until the last minute to get this information to us as it often takes several months for you to obtain it!

Send the completed list to . This will assist both you and PAACS in making sure that all documents are received by the appropriate deadline.

Document / Date e-mailed to PAACS
Birth Certificate
Marriage License
Medical License
Medical Diploma
Transcripts from Medical School, Post Graduate, Master Exam
Recommendation form from character reference
Recommendation form from medical colleague
PAACS Health Certificate
Color Photo
Essay (when assigned)
Letter from Applicant’s Supervisor

Revised June 2, 2016