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 Name Last Name
Email Address: *
Alternate Email: *
Date of Birth: *

Month Day Year
Home Address: *
Phone (Home) *

Area Code Phone Number
Phone (Work)

Area Code Phone 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)

Female Male Decline to answer
Current Gender Identity (optional) (check all that apply)

Female Male Genderqueer / Non-conforming Trans male/ Trans man Trans female / Trans woman
Preferred Pronoun (optional)

she/her/hers he/him/his they/them/theirs Decline to answer
Self-Identification (optional) (select all that apply)

Asian Black or African American American Indian or Alaska Native Hispanic, Latino, or of Spanish Origin Native Hawaiian or Pacific Islander White Decline to answer
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:

Month Day Year
Date
USMLE Step 1 Score:
USMLE Step 2 CK Date:

Month Day Year
Date
USMLE Step 2 CK Score:
USMLE Step 2 CS Date:

Month Day Year
Date
USMLE Step 2 CS Result:
USMLE Step 3 Date:

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

Month Day Year
Date
Result

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

MA Other None
License State, Number, Expiration date:
Have you ever been denied or lost a state license? *

No Yes
If yes, please explain:
Upload Documents (PDF, JPG, Doc)

Please note - maximum file size 10 MB.
Curriculum Vitae *
Recent Photograph *
USMLE exam results *
ECFMG Certificate
Personal Statement (please include date and signature) *
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