Online Application - Geriatric Fellowship | Geriatric and Palliative Medicine | Michigan Medicine

Fellowship Training in Geriatric Medicine
The Division of Geriatric and Palliative Medicine, Department of Internal Medicine
The University of Michigan Medical School, Ann Arbor, Michigan 48109-5797

Date

Applying for a Fellowship beginning (Month/Year):

Name (First/Middle/Last)

Sex

Mailing Address: Number, Street, Apt #:

City, State, Zip Code, Country

Home Phone

Work Phone

Cell Phone (optional)

E-mail Address *

Fax Number

Preferred Method of Contact

Date and Place of Birth

The following question is optional. This information will be used for statistical purposes only and will in no way affect your application:

Do you consider yourself to be a member of any of the following ethnic groups? If so, please check the box next to the group you most closely identify with.

Ethnicity

African American

Asian American

Hispanic American

Native American

Are you a U.S. citizen?

To be completed by non U.S. citizens:

Country of citizenship

Do you have a U.S. entry visa? If yes, select visa type:

Visa Number

Permanent Resident?

NOTE: If English is not your native language, please present documentation (in addition to the language examination of ECFMG) that your knowledge of the English language is sufficient to function as a Fellow in the United States. The most desirable documentation is a certification by TOEFL (Test of English as Foreign Language), Box 898, Princeton, New Jersey 08540, which can be taken around the world during the months of September, November, February, and May.

Marital Status

If married, enter name of spouse (include maiden name):

Would your acceptance of a position be contingent upon your spouse/significant other finding a suitable position in Ann Arbor?

If yes, please explain

List children's names and birthdates (optional)

Education - Undergraduate College or University

Name/Location of Institution #1

Years (inclusive)

Degree & Year

Field of Study

Name/Location of Institution #2

Years (inclusive)

Degree & Year

Field of Study

Education - Graduate or Professional/Medical Schools

Name/Location of Institution #1

Years (inclusive)

Degree

Year

Field of Study

Name/Location of Institution #2

Years (inclusive)

Degree

Year

Field of Study

Internship (include name, location, years, specialty area):

Residency (include name, location, years, specialty area):

Other Fellowships, Scholarships, Traineeships/Internships:

Awarding Agency #1

Place

Position

Years (inclusive)

Awarding Agency #2

Place

Position

Years (inclusive)

Awarding Agency #3

Place

Position

Years (inclusive)

Awarding Agency #4

Place

Position

Years (inclusive)

Please list all lapse of training activities following graduation of medical school, including dates, location and activities.

Employment History Since Graduation:

List chronologically all positions held. Include each year since graduation from undergraduate college (if applicable) and/or from Medical School:

Name and Address of Employer #1

Title of Position Held

Dates From/To

Name and Address of Employer #2

Title of Position Held

Dates From/To

Name and Address of Employer #3

Title of Position Held

Dates From/To

Name and Address of Employer #4

Title of Position Held

Dates From/To

Military Service

Branch

Rank

Position

Years (inclusive)

Medical Practice Licensures (please list state, license#, date issued and expiration date):

Medical Practice Licensures (please list state, license#, date issued and expiration date):

USMLE (United States Medical Licensing Exam) Dates, 2 & 3-Digit Scores:

Step I

Step II CK

Step II CS

Step III

To be completed by foreign medical graduates:

ECFMG Certification is mandatory for those who intend to do clinical work.

ECFMG#

Date certified

Clinical Assessment Score

Medical Specialty Board Certifications:

Name of Board #1

Year

Country

Name of Board #2

Year

Country

Extracurricular Activities:

List Memberships in National, Professional, or Related Organizations

Organization/Membership #1

Year

Organization/Membership #2

Year

Nonprofessional

Research Experience:

Describe briefly any work you may have done in an area of biomedical research; indicate outcome of this research and your preceptor.

List your publications

Academic Honors, Special Awards (Include Honor, "Awarded by" and Year):

Career Objective:

How would this Fellowship, if awarded, fit in with your career plans? Please answer in detail. Give any additional information to support your application.

Additional Information

Documents in Support of Application

Before your application can be considered: Three letters of recommendation are required (one required from your Program Director) with a complete appraisal of all the following areas: medical knowledge, patient care, professionalism, and interpersonal & communication skills. Applicant should arrange to have these submitted directly as confidential communications to the address below. The individuals submitting letters of recommendation are:

Reference #1 (Name and Address)

Reference #2 (Name and Address)

Reference #3 (Name and Address)

Personal Statement:

Optional:

Send a recent photograph (small) of yourself to the mailing address listed below or as an attachment (jpg format) to [email protected].

Curriculum Vitae can also be sent as an additional attachment to [email protected].

All documents, information, letters of recommendation, and communications should be directed to:

Caroline A. Vitale, M.D., A.G.S.F.
Director, Geriatric Medicine Fellowship Program,
University of Michigan Geriatrics Center
East Ann Arbor Health and Geriatrics Center,
4260 Plymouth Rd.
B1-313
Ann Arbor, MI 48109-5797

Direct inquiries to (734) 232-0305 or by email to [email protected].

By submitting your application, you are confirming that the above information is COMPLETE to the best of your knowledge.

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