Program to Provide to Applicant

Program to Provide to Applicant

GenericGraduateMedical Education EmploymentApplicationForm, seepages 2-6

Inaddition to thegenericapplication form, theprogram mayalso provideto/request from the applicant:

1) address to send application

2) request forapersonal statement

3) request forCV

4) request availabilityaboutcomingforapersonal interview

5) otherquestions related toyourdiscipline

6) etc.

GRADUATE MEDICALEDUCATION EMPLOYMENTAPPLICATION FORM

PleasePrint/Type

Program NameCompletingApplicationfor:

Photo

A recent photographis notarequirement,butis veryhelpful

Program StartDate:

LastName:

MiddleName:

First Name:

ContactAddress:

PermanentAddress:

HomePhoneNumber:
Work PhoneNumber:
Cell PhoneNumber:
Fax Number:
Email:
National ProviderIdentifierNumber:
Gender:
Ethnicity:
Race:
BirthDate: (mm/dd/yyyy)
BirthPlace:
CitizenshipCountry:
VisaType (ifapplicable):

Examinations

Examination / Status
(Passed/Failed) / 3-DigitScore / Date
USMLE Step1
USMLE Step2CK (clinical knowledge)
USMLE Step2 (clinical skills)
USMLE Step3

MedicalLicensure

BoardCertification?(yes/no)
Ifyes,whichBoard:
EverNamedinaMalpracticeSuit?(yes/no)
StateMedical License? (yes/no)
Ifyes,whichstate,number, expirationdate:

Educational Commission forForeignMedicalGraduatesCertification

AreyoucertifiedbytheECFMG?(yes/no)
Ifyes,ECFMGNumber:

MedicalEducation

Institution& Location / DatesAttended / Degree / DateofDegree
(mm/dd/yyyy)
Medical Education/TrainingExtendedor
Interrupted?(yes/no)
Ifyes, thereason:

MedicalEducationHonors/Awards

Education(list all graduateandundergraduateschools)

Education (not medical) / Institution& Location / Dates
Attended / Degree / DegreeDate
(mm/dd/yyyy) / Fieldof
Study
Graduate
Undergraduate

Current/PriorMedicalTraining

Experience/Specialty / Institution& Location / Program
Director / DatesAttended
(mm/dd/yyyy) / Yearsof
Training

Hospital andClinical Work Experience

Position / Hospital/Practice
Name / City/State/Zip / Dates
From mm/dd/yyyy
To mm/dd/yyyy

Publications

LanguageFluency(otherthanEnglish)

HobbiesInterests

OtherAwards/Accomplishments

Iftheanswer to any ofthequestions belowis “Yes,” providea full explanationinthespaceprovidedat the endofthisform.

1.Haveyoueverbeenreportedto theNationalPractitionerDataBank,Healthcare......  YES NO

Integrityand/orProtectionDataBank?

2.Hasyouremployment,medicalstaffappointment,panelparticipation,affiliation......  YES NO

orclinicalprivilegeseverbeenvoluntarilyorinvoluntarilysuspended,diminished, revoked,refusedorlimitedinanyhospital,healthcare facilityormanagedcare organization,IPAorPPOincludingto avoiddisciplinaryactionforreasonsrelatedto professionalcompetenceorconduct?

3.Hasyourlicenseto practiceyourprofessioninanyjurisdictioneverybeenlimited,......  YES NO

restricted,suspended,revoked,deniedor subjecttoprobationaryconditions?

4.Haveyouevervoluntarilyorinvoluntarilyrelinquishedyourlicenseto practice......  YES NO

yourprofessioninanystate?

5.Haveyoueverbeensuspended,sanctionedorotherwiserestrictedfromparticipating......  YES NO

inanyprivate,federalor statehealthinsuranceprogram(includingMedicare, Medicaidora managedcareorganization)?

6.Hasyournarcoticsregistrationcertificateeverbeenvoluntarilyorinvoluntarily......  YES NO

limited,restricted,deniedrenewal,suspendedorrevoked?

7.Haveyoueverbeendeniedmembership,membershiprenewalorbeensubject......  YES NO

to anyprofessionalreview,censureorreprimandinany medicalorganization orprofessionalsociety–local,stateor national?

8.Haveyoueverbeensubjectto disciplinaryactionbya stateagencyor......  YES NO

professionalbody(i.e.,MedicalSociety,IPRO,OPMC)?

9.Hasyourspecialtyboardcertificationorqualificationeverbeenvoluntarilyor......  YES NO

involuntarilydenied,revoked,relinquished,notrenewed,suspendedorreduced?

10.Do youhaveanypendingmisconductchargesagainstyouinthisstateoranyotherstate?......  YES NO

11.Haveyoueverbeenconvictedofamisdemeanororfelonyinanyjurisdiction?......  YES NO

12.Areyoupresentlyor haveyoueverbeensubjectto anysuspension,revocation,discontinuance,......  YES NO

limitation,restriction,monitoringorprobationaryproceedings?

13.Haveyoueverbeencited for violationofpatientrightsasset forthbythe......  YES NO

FederalLawand/orNYSDepartmentofHealthoranyotherstatedepartmentof health?

14.Hasyourprofessionalliabilityinsurancecoverageeverbeensurcharged,suspended......  YES NO

orterminatedbyactionofanyinsurancecompany?

15.Hasyourprofessionalliabilityinsurancecoverageeverbeendeniedor notrenewed......  YES NO

byactionofanyinsurancecompany?

16.Hasyourpresentprofessionalliabilityinsurancecarrierexcludedanyspecific......  YES NO

proceduresfromyourcoverage?If “Yes,”listtheprocedure(s),thedate(s)theexclusion(s)

commencedinthe spacebelow.

17.Haveanyprofessionalliabilitysuitsbeenfiledagainstyouwhicharecurrentlypending......  YES NO

inthisoranyotherstate?

18.Haveanyprofessionalliabilityjudgmentsand/orsettlementseverbeenmadeagainst......  YES NO

youoron yourbehalf?

If “Yes”to anyoftheabovequestions,pleaseexplain:

If “Yes,”listtheprocedure(s)thedate(s)theexclusion(s)commencedinthespacebelow.(Question16)

Attestation:Iherebywaiveanyconfidentialityprovisionconcerningtheinformationprovidedinthisapplication, pursuanttoNewYorkStatePublicHealthLaw section2805-k.

1.I attestthattheinformationprovidediscomplete,trueandaccurate......  TRUE FALSE

2.I agreeto updatethisformwhileitisbeingprocessed,shouldtherebeany......  TRUE FALSE

changeintheinformationprovided.

3.I understandthatanymisrepresentation,misstatementoromissiononthisform......  TRUE FALSE

couldresultinrevocationofanyprivileges/employmentgrantedand subjectto reporting accordingto NYSregulations.

4.I amnotcurrentlyusinganyillegaldrug, norhaveI duringthepasttwoyears......  TRUE FALSE

5.I authorizereleaseofreferenceinformationbyallpastandpresentemployers/......  YES NO

educationalinstitutions.

I acknowledgebymysignaturebelowthata drugtest willbea conditionofemployment.

DATE:

APPLICANTSIGNATURE

APPLICANTPRINTEDNAME

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