Pathology @ U of M

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Fellowship Application

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	Molecular genetic pathology *
Neuropathology	Pathology informatics
Pediatric pathology	Pulmonary pathology
Surgical pathology
* ACGME Accredited

Training Period for which applying:	Start date	Finish date
Training Period for which applying:

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:
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

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 can upload letters at the end of the application

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):

• Departmental Directory
• DRDA/UM Med School
• Groupwise Online
• IRBMED
• MCTP
• NIH
• PUBMED
• ULAM
• University of Michigan