Pediatric Imaging
Fellowship Training Programs
Application Checklist
Children’s Medical Center Dallas
1935 Medical District Drive
Dallas, Texas 75235
Phone 214-456-7000
Name of Applicant:
Fellowship Start Date:
Completed Application (please be sure to sign your application)
Current Curriculum Vitae
PLEASE
AFFIX
PHOTO
HERE
Personal Statement on Career Objectives & Training Expectations
Passport Sized Photo for identification purposes only
Original Medical School Transcript
USMLE 1, 2CK, 2CS an 3 or COMLEX 1, 2CE, 2PE and 3
Three Letters of Recommendation, addressed to the Program Director, must be written by
physicians who have knowledge of your clinical ability, at least one of whom is a
PEDIATRIC Radiologist. Letters of recommendation MUST be requested by the applicant
AND sent under separate cover DIRECTLY to the Program Director:
Timothy N. Booth, M.D.
Pediatric Radiology Fellowship Director
Children’s Medical Center Dallas
1935 Medical District Drive
Dallas, Texas 75235
References:
Name
Address
Email
1.
2.
3.
This application and all related communications should be addressed to:
Pediatric Radiology Fellowship
Children’s Medical Center Dallas
1935 Medical District Drive
Dallas, Texas 75235
Application for Pediatric Imaging Fellowships
Desired Fellowship Start Date:
Please select applicable fellowship program:
Pediatric Radiology
Pediatric Interventional Radiology
Pediatric Neuroradiology
GENERAL INFORMATION
Name:
Last
First
Middle (complete)
Present Address:
Maiden (if applicable)
Preferred Telephone: (
)
Alternate Telephone: (
)
Street
City
State
Zip
Email Address:
Gender:
Male
Citizenship Status:
Date of Birth:
Female
Place of Birth:
US Citizen
Ethnicity:
Permanent Resident
Are you eligible or authorized to work in the U.S.?
Yes
Military Service: Were you in the U.S. Armed Forces?
Dates of duty:
J1 Visa
H1B Visa
No Social Security Number:
Yes
No Branch:
Rank/Grade:
EDUCATION
Undergraduate
College/University:
City/State/Country:
Dates Attended:
Major:
Degree:
Major:
Degree:
Medical School:
College/University:
City/State/Country:
Dates Attended:
E.C.F.M.G. (if foreign trained): Number:
Issue Date:
Note: You must provide a copy of your valid ECFMG certificate.
Last Name ___________________________________________________
(page 2)
EXAMINATIONS/CERTIFICATIONS (attach scores/certification)
USMLE:
USMLE Step 1
Date taken (mm/yyyy):
Score/Status:
USMLE Step 2 CK
Date taken (mm/yyyy):
Score/Status:
USMLE Step 2 CS
Date taken (mm/yyyy):
Score/Status:
USMLE Step 3
Date taken (mm/yyyy):
Score/Status:
OTHER EXAMINATIONS:
Exam:
Date taken (mm/yyyy):
Score/Status:
Exam:
Date taken (mm/yyyy):
Score/Status:
Board eligible in Diagnostic Radiology – Anticipated Date of Boards?
Board certified in Diagnostic Radiology – Date of Certification?
PRIOR TRANING
Internship
Institution:
Completed Program:
Yes
No
Yes
No
Yes
No
City, State and Country:
Specialty/Area of Training:
Dates Attended (mm/yy to mm/yy):
Residency
Institution:
Completed Program:
City, State and Country:
Specialty/Area of Training:
Dates Attended (mm/yy to mm/yy):
Fellowship
Institution:
Completed Program:
City, State and Country:
Specialty/Area of Training:
Dates Attended (mm/yy to mm/yy):
MEDICAL LICENSURE
State/Province:
License Number:
Expiration Date:
State/Province:
License Number:
Expiration Date:
Have you been or currently the subject of disciplinary proceedings by any state licensure agency?
Have you been or are you currently the subject of disciplinary proceedings by any hospital?
Yes
If you answered yes to either, please explain on an additional sheet and attach to this application.
Yes
No
No
Last Name ___________________________________________________
(page 3)
EXPERIENCE
Organization & Location
Position
Dates
Other Special Training, Skills or Research Experience:
Publications (Please submit copies if available. If space below is inadequate, continue on separate blank page.):
Honors/Awards/Accomplishments:
Have you ever elected to leave any program of education and/or training prior to completion?
Yes
No
Have you even been asked or directed to leave any program of education and/or training prior to completion?
Yes
No
Are there any actions or proceedings which have involved the imposition of a sanction of suspension or dismissal from any
program of education and/or training to date?
Yes
No
Have you ever pleaded guilty to or been convicted of a crime or offense other than a minor traffic violation?
Yes
No
If YES to any of the above questions, please provide details on a separate page.
CERTIFICATION
I certify that the facts and information I have provided on this application, on other pre-employment documents and during
interviews are true and complete; and I agree that if I receive an appointment, incorrect, incomplete or falsified information will
be ground for dismissal, regardless of when discovered.
Signature:
Date: