NOTE: This Is the Short Version of the Residency/Fellowship Application. This Application

Graduate Medical Education One Medical Center Drive Osteopathic Postdoctoral Phone: (856) 566-7121 Academic Center Suite 162 Training Institution Fax: (856) 566-6222 Stratford, NJ 08084-1501 Phone: (856) 566-7121 Fax: (856) 566-6222

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * NOTE: This is the short version of the residency/fellowship application. This application is to be completed if you are currently a PGY I in a UMDNJ-SOM OPTI program and will continue in a UMDNJ-SOM OPTI residency program; will transfer from one UMDNJ-SOM OPTI residency program to another UMDNJ-SOM OPTI residency program; or will enter a UMDNJ-SOM OPTI fellowship program upon completion of a UMDNJ-SOM OPTI residency program. All other applicants must complete the long version of the residency/fellowship application. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Dear Doctor:

Attached is an application for residency and fellowship programs. This application is used for the UMDNJ-SOM OPTI residency and fellowship programs at Kennedy Memorial Hospitals-University Medical Center/Our Lady of Lourdes Medical Center, the Family Medicine Residency Program at Barnert Hospital and Christ Hospital. For application materials for the Pediatrics Residency Program at Children’s Regional Hospital at Cooper Hospital-University Medical Center, please call (856) 757-7904.

Please submit all information to the appropriate Program Director's office. Names, addresses, and phone numbers for the residency and fellowship Program Directors are on the accompanying pages. Please check with the program for deadline dates and available positions. To be considered for a residency or fellowship program, please send the following to the Program Director's Office as soon as possible:

1. Completed application (typed or printed legibly in black ink)

2. Official medical school transcript

3. Part I, II, and III Board scores

4. Three (3) current letters of recommendation (if required by residency/fellowship program)

5. Copy of contract from internship year

5. Copy of internship and/or residency certificates

6. Copy of any state license (if applicable)

7. Copy of CDS and DEA certifications

Should you have any questions, please call the Program Director's Assistant at the number listed on the accompanying pages.

Sincerely,

Carl Mogil, D.O., FACOS, FAOAO Terry Brown, M.A. Assistant Dean, Graduate Medical Education Director, Graduate Medical Education

P.S. Visit us on the web at http://som.umdnj.edu

7/6 T RESIDENCY PROGRAM DIRECTORS

For information on a specific residency program, including rotation details and deadline dates, please contact the residency program at the number listed. Completed applications should be sent directly to the residency program.

EMERGENCY MEDICINE FAMILY MEDICINE FAMILY MEDICINE Anthony J. DiPasquale, D.O. Kennedy Memorial Hospitals-UMC Christ Hospital Department of Emergency Medicine Christopher Zipp, D.O. Shari Fine, D.O. Administrative Office 42 E. Laurel Road, Suite 2100 A 324 Palisades Ave. 18 East Laurel Road Stratford, NJ 08084 Jersey City, NJ 07307 Stratford, NJ 08084 Attn: Amy Burnley Attn: Marilynn Gaeta Attn: Susan Riser (856) 566-6477 (201) 656-3597 (856) 346-7985 (856) 566-6360 {Fax} (201) 656-9247 {Fax} (856) 346-6573 {Fax}

GENERAL SURGERY INTERNAL MEDICINE- INTERNAL MEDICINE - Marc Rosen, D.O. Primary Track Traditional 42 East Laurel Road Joanne Kaiser-Smith, D.O. Joanne Kaiser-Smith, D.O. Suite 2600 42 East Laurel Road 42 East Laurel Road Stratford, NJ 08084 Suite 3100 Suite 3100 Attn: Mary Guglielmo Stratford, NJ 08084 Stratford, NJ 08084 (856) 566-6875 Attn: Karen Welding-Brown Attn: Karen Welding-Brown (856) 566-6873 {Fax} (856) 566-2753 (856) 566-2753 (856) 566-6906 {Fax} (856) 566-6906 {Fax}

OBSTETRICS/GYNECOLOGY ORTHOPEDIC SURGERY OTORHINOLARYNGOLOGY Ronald Ayers, D.O. Carl Mogil, D.O. Edward D. Scheiner, D.O. 42 East Laurel Road 42 East Laurel Road 1924 East Route 70 Suite 3200 Suite 3900 Cherry Hill, NJ 08003 Stratford, NJ 08084 Stratford, NJ 08084 Attn: Linda Hendrickson Attn: Naomi Spina Attn: Kathy Kupiec (856) 424-9200 (856) 566-7098 (856) 566-2877 (856) 424-9245 {Fax} (857) 566-6499 {Fax} (856) 566-6222 {Fax}

PSYCHIATRY UROLOGY Douglas Leonard, D.O. Jerome Pietras, D.O. 2250 Chapel Avenue 1605 Evesham Road Suite 100 Voorhees, NJ 08043 Cherry Hill, NJ 08002 Attn: Kathleen Pietras Attn: Elaine Evans (856) 428-8005 (856) 482-9000 (856) 428-8010 {Fax} (856) 482-1159 {Fax}

INTERNAL MEDICINE/EMERGENCY MEDICINE (IM/EM) (Must send application to both Directors)

Thomas Morley, D.O. (Int Med Portion) Victor Scali, D.O. (Emer Med Portion) Department of Internal Medicine Department of Emergency Medicine 42 East Laurel Road Administrative Office Suite 3100 18 East Laurel Road Stratford, NJ 08084 Stratford, NJ 08084 Attn: Karen Welding-Brown Attn: Susan Riser (856) 566-2753 (856) 346-7985 (856) 566-6906 {Fax} (856) 346-6573 {Fax}

FELLOWSHIP PROGRAM DIRECTORS For information on a specific fellowship program, including rotation details and deadline dates, please contact the fellowship program at the number listed. Completed applications should be sent directly to the fellowship program.

CARDIOLOGY CHILD/ADOLESCENT CRITICAL CARE John Hamaty, D.O. PSYCHIATRY Thomas Morley, D.O. 3001 W. Chapel Avenue Mark Sacher, D.O. 42 East Laurel Road Suite 101 2250 Chapel Avenue West Suite 3100 Cherry Hill, NJ 08002 Suite 100 Stratford, NJ 08084 Attn: Kate Jurman Cherry Hill, NJ 08002 Attn: Karen Welding (856) 755-1175 Attn: Elaine Evans (856) 566-6859 (956) 482-1587 {Fax} (856) 482-9000 (856) 566-6952 {Fax} (856) 482-1159 {Fax}

ENDOCRINOLOGY GASTROENTEROLOGY GERIATRICS (Family Medicine Louis Haenel, D.O. John Chiesa, D.O. track) 25 East Laurel Road 42 East Laurel Road Gintare Gecys, D.O. Stratford, NJ 08084 Suite 3100 42 East Laurel Road Attn: Elizabeth Flanagan Stratford, NJ 08084 Suite 1800 (856) 783-2664 Attn: Karen Welding-Brown Stratford, NJ 08084 (856) 783-8537 {Fax} (856) 566-2753 Attn: Susan Huff (856) 566-6906{Fax} (856) 566-6470 (856) 566-6419 {Fax}

GERIATRICS ( Internal Medicine GERIATRICS (Psychiatry Track) INFECTIOUS DISEASES track) Stephen Scheinthal, D.O. David Condoluci, D.O. Terri Ginsberg, D.O. 42 East Laurel Road 709 Haddonfield-Berlin Rd. 42 East Laurel Road Suite 1800 Voorhees, NJ 08043 Suite 1800 Stratford, NJ 08084 Attn: Kelly Rand Stratford, NJ 08084 Attn: Susan Huff (856) 566-3190 Attn: Susan Huff (856) 566-6470 (856) 566-1903 {Fax} (856) 566-6470 (856) 566-6419 {Fax} (856) 566-6419 {Fax}

NEPHROLOGY ONCOLOGY OSTEO PATHIC Joseph Pitone, D.O. H. Timothy Dombrowski, D.O. MANIPULATIVE MEDICINE 201 Laurel Oak Road Alex Hageboutros, M.D. David Mason, D.O. Voorhees, NJ 08043 42 East Laurel Road 42 East Laurel Road Attn: Lynda Dunn Suite 3100 Suite 1700 (856) 566-5478 Stratford, NJ 08084 Stratford, NJ 08084 (856) 566-9561 {Fax} Attn: Karen Welding-Brown Attn: Lisa Murphy (856) 566-2753 (856) 566-2745 (856) 566-6906 {Fax} (856) 566-2733 {Fax}

PULMONARY James Giudice, D.O. 42 East Laurel Road Suite 3100 Stratford, NJ 08084 Attn: Karen Welding-Brown (856) 566-6859 (856) 566-6952 {Fax}

SLEEP MEDICINE VASCULAR SURGERY Amitta Vasoya, D.O. Charles Dietzek, D.O. 42 E. Laurel Rd. 42 East Laurel Road Suite 3100 Suite 2600 Stratford, NJ 08084 Stratford, NJ 08084 Attn: Karen Welding-Brown Attn: Mary Guglielmo (856)-566-6859 (856) 566-6875 (856-566-6952 (Fax) (856) 566-6873 {Fax}

A PPLICATION FOR RESIDENCY/FELLOWSHIP TRAINING

UMDNJ-School of Osteopathic Medicine

Osteopathic Postdoctoral Training Institution

Application for Residency/Fellowship in ______

For Post Graduate Year (i.e., PGY 2, 3)______beginning July, ______

PLEASE TYPE OR PRINT CLEARLY IN BLACK INK.

Name ______(Last) (First) (Middle)

Social Security No. ______AOA No. ______

Present Address ______Phone (______) ______

______Zip ______

Permanent Address ______Phone (______) ______

______Zip ______

E-Mail Address

Emergency Contact ______

Address ______

Phone: Day (______)______Night (______)______

Are you a: _____ U.S. Citizen? _____ Permanent Resident? _____Other?* * If other, please provide documentation for eligibility to be employed in the U.S.

Pre-Professional Education: List, in order, Colleges or Universities you have attended.

Dates of Degree Name of College Location Attendance and Date

______

Professional Education: List medical school(s) you attended.

Dates of Degree Name of Medical School Location Attendance and Date

______

Post-Graduate Education:

Internship: Track ______Dates ______/_____/______to ______/_____/______

Institution ______City: ______State: ______

7/04 S-1 Post-Graduate Education (continued): Residency: Specialty ______Dates ______/_____/______to ______/_____/______

Institution ______City: ______State: ______

National Board of Osteopathic Medical Examiners board scores: Part I ______Date of Examination ______

Part II ______Date of Examination ______

Part III ______Date of Examination ______

Do you plan on taking the USMLE? ______No ______Yes, Date of Exam ______

New Jersey Medical License Number ______

New Jersey CDS Number: ______Federal DEA Registration Number: ______

Has your New Jersey medical license, New Jersey CDS or Federal DEA ever been suspended or revoked?

Yes ______No ______

If yes, please explain: ______

Do you have a license to practice medicine in any other state(s)? Yes ______No ______

If yes, list states, dates and license numbers.

State Dates License Number

______

Have you ever been involved in a malpractice suit? Yes ______No ______

If yes, please give the date and nature of case(s) and status of the suit, i.e. open, dismissed, closed with payment.

Date Nature of Case

______

______(Applicant's Signature) (Date)

UMDNJ does not discriminate in admissions or access to its programs and activities on the basis of race/color, national origin, ethnicity, religion/creed, disability, age, marital status, sex, sexual orientation or veteran’s status. Appointment to this position requires that you are not listed by the Office of Inspector General (OIG) and/or the General Services Administration (GSA) as excluded from participating in federal health care, research, or other grant programs.

7/04 S-2 UMDNJ-School of Osteopathic Medicine

Osteopathic Postdoctoral Training Institution

AUTHORIZATION FOR RELEASE OF INFORMATION AND

RELEASE FROM CIVIL LIABILITY

I specifically authorize the University and its authorized representatives to consult with the management and members of the medical staffs of other hospitals, health care facilities, previous colleges/universities and/or other institutions with which I have been associated and with others who may have information bearing on my professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior, or any other matter. This University or its authorized representatives may inquire and inspect all records and documents that may be material to the above.

I hereby release from civil liability any individual or institution reviewing or providing information relative to my application for residency/fellowship at UMDNJ-SOM OPTI.

______(Applicant's Signature) (Date)

______(Print Name)

7/04 S-3