OFFICE OF ACADEMIC AFFAIRS HOUSE STAFF INITIAL APPLICATION (Revised 10/2010)
Resident/Fellow Last name: First: Middle:
SS#: Date of Birth: / / Place of Birth: Gender: Male Female
Program Name: Department Fund #: Country of Citizenship: USA -or- Other Work Authorization: (please Visa Status (specify type – J1 or H1B): Expiration Date: / / specify):
Present Address: City: State: Zip:
Home Phone #: ( ) - Cell/Mobile #: ( ) - Email Address:
Present Address: City: State: Zip:
Permanent Cell/Mobile #: ( ) - Permanent Home Phone #: ( ) -
Medical School: Degree: Graduation Date: / /
ACADEMIC YEAR FOR WHICH YOU ARE APPLYING / /
TRAINING LEVEL: 1st year 2nd year 3rd year 4th year 5th year 6th year 7TH year
SECTION I. Contains the programs sponsored by one of the hospitals listed below. The training in these programs occurs primarily at the sponsoring institution. There may also be training taking place at other System facilities through structured rotations. Please select the sponsoring hospital of your choice and then indicate to which program at that hospital you are applying.
Facility: (check one) NSUH LIJ Glen Cove Forest Hills Southside Plainview Lenox Hill DENTAL MEDICINE INTERNAL MEDICINE PATHOLOGY Cardiothoracic Surgery GEN. PRACTICE DENTISTRY (Continued) CYTOPATHOLOGY Oral & Maxillofacial Surgery Hospice & Palliative Care SURGERY Oral & Maxillofacial Pathology Interventional Cardiology PEDIATRICS Podiatry Pediatric Dentistry Nephrology Allergy/Immunology Pediatric Pulmonary/Critical Care Child Neurology Laparoscopic EMERGENCY MEDICINE Rheumatology Dev/Behavioral Critical Care Emergency Med.* Sleep Medicine EM/Internal Med. PHYSICAL MEDICINE & UROLOGY Toxicology NEUROLOGY REHABILITATION ADULT UROLOGY Sports Medicine Clinical Neurophysiology PEDIATRIC UROLOGY Movement Disorders PSYCHIATRY ENDOUROLOGY Family Practice Medicine Consultation and Liaison NEUROUROLOGY NEUROSURGERY Geriatric Psychiatry INTERNAL MEDICINE Addiction Psychiatry Cardiology OBSTETRICS/GYNECOLOGY* Endocrinology MATERNAL & FETAL MED RADIOLOGY, DIAGNOSTIC Gastroenterology UROGYNECOLOGY Interventional/Vascular General Internal Medicine* Neuroradiology Geriatric Medicine ORTHOPAEDIC SURGERY Pediatric Radiology Hem/Oncology Body Imaging
1 Section II - Contains a list of merged programs. Training in these programs is conducted equally between the LIJ and NSUH campuses. There may also be some training occurring at other System facilities through structured rotations. Please indicate to which of the merged program you are applying.
Facility: (check one) NSUH LIJ Glen Cove Forest Hills Southside Plainview Lenox Hill NEUROLOGY PEDIATRICS PEDIATRICS (CONTINUED) SURGERY Adolescent Med. Hematology/Oncology Colon Rectal OPHTHALMOLOGY Cardiology Infectious Diseases General Surgery* Critical Care Med. Neonatal-Perinatal Med. Vascular Surgery PATHOLOGY Emergency Medicine Rheumatology ANATOMICAL&CLINICAL Endocrinology Gastroenterology &Nutrition PSYCHIATRY General Pediatrics* ADULT PSYCHIATRY Child & Adolescent
RADIOLOGY Nuclear Medicine,Special Competence
*PGY1 positions are offered through the NRMP and are Categorical UNIVERSITY EDUCATION MEDICAL / DENTAL SCHOOL (S) (List exact name of all school attended, dates must include day, month and year)
Name: Degree: Date From: / / To: / / Zip: Address: City: State:
Name: Degree: Date From: / / To: / /
Address: City: State: Zip:
Honors, Scholastic Achievement: UNDERGRADUATE/GRADUATE SCHOOL (S) (List exact name of school (s), dates must include day, month and year
Name: Degree: Date From: / / To: / /
Address: City: State: Zip:
Name: Degree: Date From: / / To: / /
Address: City: State: Zip:
Honors, Scholastic Achievement:
2-Hospital Program
Address: City: State: Zip:
2 PGY Level: Position: 1 2 3 4 Date(s) From: / / To: / / 5 6 7 8
3- Hospital Program
Address: City: State: Zip:
PGY Level: 1 2 3 4 Position: 5 6 7 8 Date(s)From: / / To: / /
OTHER EMPLOYMENT:
1-Name of Institution: Job Title
Address: City: State: Zip: Date of employment: Date(s) From: / / To: / /
Did you leave in good standing? Yes or No
If No please explain
2-Name of Institution Job Title
Address: City: State: Zip:
Date of employment: Date(s) From: / / To: / /
Did you leave in good standing? Yes or No
If No please explain
3-Name of Institution Job Title
Address: City: State: Zip:
Date of employment: Date(s) From: / / To: / /
Did you leave in good standing? Yes or No
If No please explain
EXAMINATIONS / LICENSURE S USMLE Dates / / core/Parts I IICK ICS
ECFMG Cert #: Expiration date: / /
FMGEMS Dates / / FORMTEXT Score / Parts I II III
Other
State Licensure Dates / / Number
State Licensure Dates / / Number 3 PUBLICATIONS / RESEARCH EXPERIENCE
Current project: updating a review of seizures and epilepsy in cancer patients; specifically, examining interactions between chemotherapy agents and newer antiepileptic drugs.
SPECIALTY INTEREST / INTEREST IN NORTH SHORE-LONG ISLAND HEALTH SYSTEM. Please indicate how you learned about the NSLIJHS program and what your future interests may be.
At Montefiore, our neurology residents rotate with LIJ neurology residents on the consult service. I have really enjoyed working with them, and from them learned about the excellent teaching and training at the LIJ neurophysiology fellowship.
LETTERS OF RECOMMENDATION / MAILING INSTRUCTIONS You must complete this application in duplicate and forward one copy to the Chairman of the Department or Training Program Director to which you are applying at the North Shore-LIJ Health System. Submit the second copy to the Dean’s Office at your school. YOUR DEAN’S LETTER, TRANSCRIPT AND ALL LETTERS OF RECOMMENDATION MUST BE ADDRESSED TO THE CHAIRMAN OF THE DEPARTMENT OR TRAINING PROGRAM DIRECTOR TO WHICH YOU ARE APPLYING. If you wish, you may include a brief biographical sketch. (Applicants for Pediatrics, please see special instructions in Chairmen’s letter.)
The policy of the Health System requires all prospective House Staff Officers undergo a toxicology screen prior to the commencement of their training. All offers for such training are conditional upon satisfactorily passing both the toxicology screen and a medical examination.
To the best of my knowledge, all of the above information is correct and true, and no such attempt has been made to conceal pertinent information. I authorize my former employers, schools and personal references to provide any information they may have regarding me, whether or not it is on their records. I hereby release them and their company and/or institutions from any and all liability for divulging same. I understand that if any information given by me in this application is false or misleading I will be subject to immediate dismissal, and I agree to hold the Health System and its agents blameless in that event.
/ / Signature Date
North Shore-LIJ Health System is an equal opportunity employer. Federal, State and local laws prohibit discrimination based upon race, color, sex, national origin, age, religion, sexual preference or handicap.
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