University of Michigan Health System
Department of Pathology
Application for Pathology Fellowships
Applicant Name
Last Name First Middle

Fellowship Type
This application is being made for a fellowship in (please check one):
Blood banking/Transfusion medicine * Breast pathology
Cytopathology * Dermatopathology *
Forensic pathology Gastrointestinal pathology
Genitourinary pathology Gynecologic pathology
Hematopathology * HLA Tissue Typing
Molecular genetic pathology * Neuropathology *
Pathology informatics Pediatric pathology *
Pulmonary pathology Surgical pathology * 
* ACGME Accredited

Training Period for which applying: Start date Finish date

Personal Data
Other Names Used:
Present Address
Street City State Zip / Postal Code
Permanent Address
Street City State Zip / Postal Code
Telephone
Home Work Mobile Fax
Email: (REQUIRED)
Date of Birth Place of Birth
Citizenship
If not a U.S. citizen, type of Visa *:
* A J-1 visa sponsored by ECFMG is required for ACGME fellowships. Non-ACGME fellowships require candidates to be eligible for HIB visas

Education
(Mo/Yr)   (Mo/Yr) (Undergraduate School) (Major) (Degree)
  to  
(Mo/Yr)   (Mo/Yr) (Graduate School, if applicable) (Major) (Degree)
  to  
(Mo/Yr)   (Mo/Yr) (Medical School) (Degree)
  to  
(Mo/Yr)   (Mo/Yr) (Residency) (AP, CP, AP/CP, Other)
  to  
(Mo/Yr)   (Mo/Yr) (Other GME, if applicable) (Area of training)
  to  
(Mo/Yr)   (Mo/Yr) (Other GME, if applicable) (Area of Training)
  to  

Other Experience
In chronological order, list other educational experiences, jobs, military service, or training that is not accounted for above
(Mo/Yr)   (Mo/Yr)  
  to  
(Mo/Yr)   (Mo/Yr)  
  to  
(Mo/Yr)   (Mo/Yr)  
  to  

National Boards
Please indicate national board examination dates and results received.
USMLE Step 1 USMLE Step 2 USMLE Step 3
Date passed Score CK - Date passed Score CS - Date passed Score (optional) Date passed Score
For graduates of international medical schools, are you ECFMG-certified? Yes No   If yes, list date certified (Mo/Yr):
COMLEX Level 1 COMLEX Level 2 COMLEX Level 3
Date passed Score Date passed Score Date passed Score

Medical Licensure
Please list any states in which you hold a license to practice medicine. Please provide a license number. If an application is pending in a state, please write "pending".
(State) (Date Issued) (Medical License Number) (Active?)
Yes    No
(State #2) (Date Issued) (Medical License Number) (Active?)
Yes    No
Have you ever been reprimanded, or had your license suspended or revoked in any of these states? Yes (Please explain in an attached sheet)
No
Have you ever been named in (and/or had a judgement against you) in a medical malpractice legal suit? Yes (Please explain in an attached sheet)
No

Board Certification
Please indicate any areas of board certification
Board Area of Certification Date of Certification
Honors, Awards, Publications, Memberships, Leadership/Research Experience
Include this information on your CV, and upload this document at the end of the application

Letters of Recommendation and/or References
Please list the individuals who will write or have provided your letters of recommendation
At least three are required, and must include comments related to your clinical competency/ability. You will have the option to upload letters at the end of the application if they are available or they can be sent directly to the fellowship director.
 
Reference #1
Name Title
Institution
Address City State Zip/Postal Code
Reference #2
Name Title
Institution
Address City State Zip/Postal Code
Reference #3
Name Title
Institution
Address City State Zip/Postal Code
Reference #4 (Optional)
Name Title
Institution
Address City State Zip/Postal Code

Personal Statement
File Upload
Passport Photo:
CV:
Letter #1:
Letter #2:
Letter #3:
Letter #4 (Optional):
Additional File (Optional):