Application for Fellowship

Date

Date you wish to begin

PERSONAL DATA

Name in full (First, Middle, Last)
Current Mailing Address - (Street)
(City)
(State)
(Zip)
Telephone: Home
Office, ext.
Cell
E-mail address
Gender
Date of Birth
Place of Birth
Are you a U.S. Citizen?

LICENSURE ELIGIBILITY REQUIREMENTS

For Anesthesiologists:
To receive credit from the American Board of Anesthesiology, the Board requires that you obtain medical licensure or pass a qualifying examination before beginning your third postgraduate year.

For Surgeons:

To receive credit from the American Board of Surgery, the Board requires that you finish your surgical residency prior to being allowed to sit for the ABS examination in Critical Care Medicine. You may take the Fellowship at any appropriate time during your surgical residency.

Others (Emergency Medicine, Internal Medicine, etc)

At this time your Board Certification Process will be through the European Society for Intensive Care Medicine. You will become eligible for this examination, leading to the European Diploma in Intensive Care Medicine, after finishing your Fellowship.

Qualifying Examinations

United States Medical Licensing Examination:
Step 1 Step 2 Step 3

National Boards:


Part I Score

Part II Score

Part III Score

Number

Date

FLEX: State

Date

Licensure

State of Licensure, Date, License Number

EDUCATION AND EXPERIENCE

Premedical College

Dates

Location

Degrees

Medical School

Graduation Date - Month/Year

Location

Honors

Hospital currently working in

List chronologically your activities from the
time of graduation from medical school to the present.
Specify type of internship or post-MD specialty training.

List From when to when, Activity, Place,
Degree if any, Program Director

Membership in professional societies and others.

MILITARY OBLIGATIONS

Are you in the reserves?
If yes, what branch?
Dates of Commitment

LETTERS OF RECOMMENDATION

At least three letters of reference are required. One must be from the Dean of your medical school and at least two others should be from physicians who have observed or supervised you during medical school or during your PG1 or other recent training program, as applicable.

Please list the names of all your references.
Please have them write directly to us at the address on last page.
Please include Name Address City State Zip

CITIZENSHIP (Complete if applicable)

IF A NATURALIZED CITIZEN: Naturalization Certificate Number

Location

Date

IF NOT A U.S. CITIZEN:

Immigrants


Alien Registration Card Number

Expiration Date

Non-Immigrant Aliens


Visa Number

Expiration Date

Refugees

If you do not have an alien registration card or a visa, please e-mail us a scan of the card attached to your passport by the Immigration Service and complete the section below:

Country that issued your passport
Passport Number
Current Status
Are you a graduate of a foreign medical school?
If yes, please give name of school and year of graduation
ECFMG Number
Standard or Interim
Have you passed the Visa Qualifying Exam (VQE)
Date of VQE
Have you received licensure from a country other than U.S.?
If so, which Country
Province
Date

Please include a copy of:	Recent photograph (passport type)
If applicable:	Copy ECFMG and VQE certificate Copy Visa (for Non-Immigrant Alien) Copy Alien Registration Card (for Immigrant Non-Citizen)

Print and mail completed application, along with any other necessary documents to:

A. Joseph Layon, MD, FACP
Director, CCM Fellowship Program
Department of Anesthesiology
University of Florida
Box 100254
Gainesville, FL 32610-0254