BWH Abdominal Imaging and Intervention Fellowship Application Form

BWH Abdominal Imaging and Intervention Fellowship Application Form
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.
Program Year
Name:*

First NameLast Name
Email Address:*
Alternate Email:*
Date of Birth:*

MonthDayYear
Home Address:*
Phone (Home)*

Area CodePhone Number
Phone (Work)

Area CodePhone Number
Citizenship status:*

US Other

Citizenship
If Other, country of citizenship and VISA type/expiration date:
What sex were you assigned on your birth certificate (optional)

FemaleMaleDecline to answer
Current Gender Identity (optional) (check all that apply)

FemaleMaleGenderqueer / Non-conformingTrans male/ Trans manTrans female / Trans womanOther
Preferred Pronoun (optional)

she/her/hershe/him/histhey/them/theirsDecline to answer
Self-Identification (optional) (select all that apply)

AsianBlack or African AmericanAmerican Indian or Alaska NativeHispanic, Latino, or of Spanish OriginNative Hawaiian or Pacific IslanderWhiteDecline to answerOther
Education and Training
Premedical College (Institution, Degree, Year completed):*
Medical School (Institution, Degree, Year completed):*
Medical and Specialty Training
Internship (Type, Hospital Name & Address, Dates of training)*
Residency (Type, Hospital Name & Address, Dates of training)*
Other Training/Position (Clinical or Research)
Certifications and Licenses
USMLE Step 1 Date:

MonthDayYear
Date
USMLE Step 1 Score:
USMLE Step 2 CK Date:

MonthDayYear
Date
USMLE Step 2 CK Score:
USMLE Step 2 CS Date:

MonthDayYear
Date
USMLE Step 2 CS Result:
USMLE Step 3 Date:

MonthDayYear
Date
USMLE Step 3 Score:
LMCC Results and Date (if applicable):
ABR Core Exam
ABR Core Exam Date

MonthDayYear
Date
Result

PassFail
Overall Score
Physics Subscore
Medical Licensing
State(s) in which you are licensed to practice medicine:*

MAOtherNone
License State, Number, Expiration date:
Have you ever been denied or lost a state license?*

NoYes
If yes, please explain:
Upload Documents (PDF, JPG, Doc)

Please note - maximum file size 10 MB.
Curriculum Vitae*

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Recent Photograph*

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USMLE exam results*

Upload a File

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ECFMG Certificate

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Personal Statement (please include date and signature)*

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Letters of Reference

Please list the names and institutions of three physicians who will be writing recommendation letters for you.
Reference #1: Name*
Reference #1: Institution*
Reference #1: Email*
Reference #2: Name*
Reference #2: Institution*
Reference #2: Email*
Reference #3: Name*
Reference #3: Institution*
Reference #3: Email*
Please mail letters to:

Alisa Greer
Division of Abdominal Imaging and Intervention
Department of Radiology
Brigham and Women's Hospital
75 Francis Street, Boston, MA 02115

Phone: (617) 732-6304
Fax: (617) 732-6317
Email: agreer@bwh.harvard.edu
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BWH Abdominal Imaging and Intervention Fellowship Application Form

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Education and Training

Medical and Specialty Training

Certifications and Licenses

ABR Core Exam

Medical Licensing

Upload Documents (PDF, JPG, Doc)

Letters of Reference