Jefferson

Check program for which you are applying

Name in full: ______Last First Middle Present Mailing Address: E-mail: ______

Telephone: Day ______Evening ______Social Security No.:______

Permanent Mailing Address:

Pre-Medical College Attended with Degrees Conferred:

Medical College Attended with Year of Graduation:

Internship: Dates of Start and Completion ______Type______

Name and Address of : ______

Residency: Dates of Start and Completion ______Type______

Name and Address of Hospital: ______

Fellowship: Dates of Start and Completion ______

Name and Address of Hospital: ______

For all applicants: The application must be accompanied by (1) transcript of medical school record or Dean’s letter from medical school; (2) USMLE I, II, III scores; (3) one letter of recommendation from Residency Program Director; (4) one letter of recommendation from Fellowship Program Director.

Publications (if any): ______

Research Experience: ______

Medical License No.: ______State and Year: ______

Signature Date of Application FOR GRADUATES OF INTERNATIONAL MEDICAL SCHOOLS THE APPLICATION MUST BE ACCOMPANIED BY: (1) A COPY OF MEDICAL SCHOOL DIPLOMA (2) LETTER FROM INTERNSHIP HOSPITAL (3) LETTER FROM TWO SPONSORS (PREFERABLY INDIVIDUALS IN THE UNITED STATES) (4) A COPY OF STANDARD ECFMG CERTIFICATE

ALL INTERNATIONAL MEDICAL GRADUATES ARE TO ANSWER THE FOLLOWING QUESTIONS:

NATIONALITY: ______

DATE OF ENTRANCE TO THE UNITED STATES: ______

PLACE OF BIRTH (CITY): ______

TYPE OF VISA ______VISA # ______EXPIRATION DATE ______

PASSPORT# ______ISSUED BY (COUNTRY) ______EXPIRATION ______

ECFMG CERTIFICATE# ______

EXPIRATION DATE OF I-94 FORM (ARRIVAL-DEPARTURE RECORD) ______

Signature Date of Application

When completed please return to one of the following:

Douglas B. Esberg, MD Program Director Clinical Cardiac Electrophysiology Fellowship Medical Office Building East 100 East Lancaster Avenue, Suite 558 Wynnewood, PA 19096 484.476.2682

CLINICAL CARDIAC ELECTROPHYSIOLOGY

Requirements:

Completed applications must contain a medical school transcript, curriculum vitae, personal statement, USMLE Report (Steps 1, 2 and 3), ABIM Board Score Report, and three letters of recommendation. One of the letters must be from the Program Director. Letters of recommendation should be directed to the Program Director, Dr. Douglas Esberg.

Deadline for Receipt:

Completed applications will be accepted through January 31, 2011. Selected candidates will be invited for an interview.

Questions should be directed to:

Rose Marie Wells, Program Coordinator Lankenau Heart Institute 558 Lankenau MOB East 100 East Lancaster Avenue Wynnewood, PA 19096 484.476.2682 [email protected]

The mission of Main Line Health is to provide a Lankenau Medical Center, a member of Main Lankenau Medical Center is located in comprehensive range of safe, high-quality health Line Health, is recognized as a national Wynnewood, Pennsylvania, part of 's services, complemented by related educational leader in advancing new options to diagnose Main Line suburbs, which are famous for their and research activities, that meet and treat illness, protect against disease and outstanding environment and quality of life. needs and improve the quality of life in the save lives. Located on a 93-acre suburban About fifteen minutes away by either car or public communities we serve. campus just outside of Philadelphia, transportation, Center City Philadelphia offers Lankenau Medical Center is a 389-bed, not- attractions as varied as regional and national for-profit teaching hospital that includes one theater, the Pennsylvania ballet, the Philadelphia of the nation’s leading cardiovascular Orchestra, exciting professional and collegiate Founded in 1985, Main Line Health (MLH) is a centers; the Lankenau Institute of Medical sports, a wide range of film and music outlets, not-for-profit health system serving portions of Research, one of the few freestanding the Mummers Parade, and hundreds of Philadelphia and its western suburbs. At its core hospital-associated research centers in the restaurants serving food ranging from local are four of the region’s respected acute care nation; and the Annenberg Conference favorites, like cheese steaks, to nationally —Lankenau Medical Center, Bryn Mawr Center for Medical Education. Lankenau renowned French cuisine and other ethnic Hospital, and Riddle Hospital—as offers state-of-the-art services from cancer specialties. Philadelphia also features the well as one of the nation’s premier facilities for care to maternity care. Lankenau is ranked Philadelphia Art Museum and the Franklin rehabilitative medicine, Bryn Mawr Rehab as number six in Pennsylvania and number Institute, among the 26 museums within the city Hospital; Mirmont Treatment Center for drug and four in the Philadelphia metro area in U.S. alone; the 8,700-acre Fairmount Park; Penn's alcohol recovery; and HomeCare & Hospice, a News & World Report’s Best Hospitals. Landing, the Morris Arboretum; and historic sites, home health service. Main Line Health also Lankenau Medical Center is also ranked including Independence Hall and the Liberty Bell. consists of Main Line HealthCare, one of the nationally for diabetes and endocrinology, region’s largest multi-specialty physician and is high-performing in eight specialties: Attractions outside the city include the networks, and the Lankenau Institute for Medical cardiology & heart surgery, diabetes & Brandywine Museum on the Wyeth family estate; Research, a non-profit biomedical research endocrinology, gastroenterology & GI and seven parks in the area offer swimming, organization located on the campus of Lankenau surgery, geriatrics, neurology & hiking, riding, and fishing, among other activities. Medical Center. Main Line Health is also neurosurgery, orthopaedics, pulmonology New York City and Baltimore, Maryland, are both comprised of four outpatient health centers and urology. Lankenau has achieved The near enough for day trips, and the Pocono located in Broomall, Collegeville, Exton and Joint Commission’s Gold Seal of Mountains and New Jersey, Delaware, and Newtown Square. Main Line Health Hospitals, Approval for stroke care and breast Maryland beaches all offer weekend alternatives. with more than 10,000 employees and 2,000 cancer care and is one of the nation’s Top Nearby historical sites include Valley Forge physicians, are the recipients of numerous Performing Hospitals for heart attack, heart National Park, the battleground at Gettysburg, awards for quality care and service, including failure, pneumonia and surgical care. and other reminders of the area's long history. System Magnet® designation, the nation’s Lankenau has also been ranked for highest distinction for nursing excellence. Main multiple years as one of the top 50 cardiovascular hospitals in the nation Line Health is among the area’s leaders in Lankenau is located just outside the western city by Truven Health Analytics. Lankenau medicine, providing advanced patient-centered limits of Philadelphia in Wynnewood, has earned Magnet® designation for the care, education and research to help our Pennsylvania. Philadelphia is served by national third time for its superior nursing staff. community stay healthy. train and bus transportation, and by national and international air transportation. Once in Thomas Jefferson University Hospitals have Founded in 1927, the Lankenau Institute for Philadelphia, you can get to Lankenau by car, major programs in a wide range of clinical Medical Research (LIMR) is an independent, taxi, train, or bus via the following directions: specialties. Services are delivered at five nonprofit biomedical research center located primary locations—Thomas Jefferson University in suburban Philadelphia on the campus of From Center City, Philadelphia Hospital (the main hospital facility, which was Lankenau Medical Center. Part of Main Line established in 1825) and Jefferson Hospital for Health, LIMR is one of the few freestanding, BY TRAIN, from Philadelphia's 30th Street or Neuroscience, both in Center City Philadelphia; hospital associated medical research centers Suburban Station, take SEPTA's R5 "Paoli Local" Jefferson's Methodist Hospital and Jefferson at in the nation. The faculty and staff at the to either Overbrook or Wynnewood. From the Navy Yard, both in South Philadelphia; and Institute are dedicated to advancing an Overbrook, it is a fifteen-minute walk up City Ave. Jefferson at Voorhees in South Jersey. There understanding of the causes of cancer, heart to Lancaster, then west along Lancaster to the are also various radiation therapy satellite disease and diabetes. This information is Hospital From Wynnewood, it is possible to catch locations throughout the region. Formerly a used to help improve diagnosis and the 105 bus; ask a SEPTA official or look for the division of Thomas Jefferson University, the treatment of these diseases as well as find sign marking the stop in the parking tot across Hospital was separated from the University to ways to prevent them. LIMR is also the street. become a founding member of the Jefferson committed to extending the boundaries of Health System in 1995. The Hospital expanded human health and well-being through BY SUBWAY AND BUS, take the Market- its services to the community with the merger of technology development and the training of Frankford Elevated line to the 69th Street termi- Methodist Hospital as a division of Thomas the next generation of scientists and nal, and transfer to the 105 bus to Lankenau. The Jefferson University Hospitals in 1996. physicians. SEPTA G bus, which serves major portions of the city, also stops at Lankenau. From Center City, Philadelphia (continued) From the South Take I-95 to Philadelphia. Exit 95 onto Route Accommodations are offered as suggestions BY CAR, take Route 76 (the Schuylkill 476 North (the Blue Route). Exit 476 at the only. Expressway) west to City Avenue (Route 1). Exit Route 1 exit. Follow Route 1 North several onto City Avenue, turn right, at the bottom of the miles to Route 30 (Lancaster Avenue). Turn Holiday Inn ramp, and travel south to the intersection of City left on Route 30 (west) to first traffic light. City Ave &, Presidential Blvd. and Lancaster Avenue (Route 30). Turn right on Turn left into Lankenau drive. Philadelphia, PA 19131. 215/477-0200 Lancaster to the first light. Turn left into the Approximately three miles north of Lankenau Lankenau drive. From the East/West Medical Center on City Avenue (Route 1, near Take the Pennsylvania Turnpike to Valley junction of Schuylkill Expressway). Contact the From the Airport Forge. Exit onto Route 76 East (Schuylkill Reservations Manager and request the A SEPTA train runs from the Philadelphia Expressway). Follow to Route 1 exit (City "Lankenau Patient Relations Rate" at the time International Airport to 30th Street Station. By Avenue). Exit south onto Route 1; follow to you make your reservation. #65 bus to 63rd and car, travel south from the airport on I-95 to the Route 30 (Lancaster Avenue). Turn right Lancaster Avenue, transfer to the "G" bus to exit for Route 476 (the Blue Route). Travel north (west) onto Route 30 to first traffic light. Turn come to Lankenau Medical Center. on the Blue Route to the Route 1 exit. Follow left into Lankenau drive. Route 1 north several miles to Route 30 Hilton Philadelphia City Avenue (Lancaster Avenue). Turn left on Route 30 (west) From the Western Suburbs 4200 City Avenue to first traffic Light. Turn left into Lankenau drive. Take Route 30 (Lancaster Avenue) to the Philadelphia, PA 19131. 215/879-4000 Lankenau entrance, which is Located just Approximately three miles north of Lankenau If driving to Philadelphia and Lankenau Medical west of City Avenue. Medical Center on City Avenue (Route 1, near Center, use the following directions: junction of Schuylkill Expressway). For From the Southern Suburbs reservations, request the Lankenau Preferred From the North Take Route 1 north to Route 30. Go west on Rate. Take I-95 to Philadelphia. Exit 95 onto Route Route 30 approximately 1/4 mile to the 676-76 West in Philadelphia. Exit Route 76 onto Lankenau entrance. Radnor Hotel City Avenue, and turn right at the bottom of the Lancaster Avenue ramp. Travel south on City Avenue (Route 1) to St. Davids, PA 19087. 610/688-5800 the intersection of Lancaster Avenue (Route 30). Approximately five miles west of Lankenau Turn right onto Lancaster Avenue to the first Medical Center on Lancaster Avenue (Route 30). traffic light. Turn left into Lankenau drive. Bus service available until 6:30 p.m. Ask for the Corporate Rate.

Wayne Hotel 139 East Lancaster Ave., Wayne, PA 19087. 610/687-5000 Victorian hotel approximately seven miles west of Lankenau Medical Center on Lancaster Avenue (Route 30). Ask for the Corporate Rate.