Application for Regional Anesthesia & Acute Pain Medicine Fellowship at Iowa

Background Information

Specialty:

Training applied for to begin on:

Name (last, first, middle):

Present address:

Permanent address:

E-Mail address:

Hospital or office phone number:

Cell phone number:

Country of citizenship:

If you are not a citizen of the U.S., what is your visa status?

H-1b

J-1

J-2 with EAD

F-1 with OPT

Green card number (if applicable):

If applicable, have you passed the Foreign Medical Graduation Examination in Medical Sciences?

Yes

Iowa Medical License Number:

ECFMG Number:

Undergraduate/Graduate Education

Institution	Attended from	Attended to	Degree & field	Date received


Medical Education:


Internship and Residency:

Previous Research Experience

Previous Private Practice

Location	From	To

Publications

(Please scan copies to tammi-steffen@uiowa.edu or fax to (319) 356-2940, ATTN: Fellowship Coordinator):

Scholarships, Prizes, or Awards-Memberships in Honorary/Professional Societies

Military Experience

Branch	From	To

Highest Rank:	Reserve Commission:

Applicants are requested to have THREE LETTERS OF RECOMMENDATION sent or FAXed promptly. These letters should come from those persons best qualified to vouch for the character and professional qualifications of the applicant.

An unmounted recent photograph of applicant must accompany this application or be provided at time of interview.

If an appointment is offered which I accept, I hereby agree and pledge myself as follows: 1) to serve during the entire term to which I may be appointed, and 2) to comply faithfully with the rules and regulations of the University of Iowa Hospitals and Clinics now in effect and those which may be adopted during my term of appointment.

The University of Iowa Hospitals and Clinics requests this information for the purpose of processing your application for a position on our house staff. No persons outside the University are routinely provided this information without your consent. Responses to all items are required. If you fail to provide the required information, The University of Iowa Hospitals and Clinics may be unable to process your application.