APPLICATION FOR POSTGRADUATE TRAINING IN ANESTHESIA
AT
UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE
HEALTH SCIENCE CENTER
P.O. Box 100254 UFHSC
Gainesville, FL 32610-0254
352.265.0077
PHOTO
Date ________________
Date you wish to begin ________________
1. PERSONAL DATA
Name in Full _____________________________________________________________________________________________
First
Middle
Last
Current Mailing address ___________________________________________________________________________________
Street
_________________________________________________________________________________________________________
City
State
Zip
Telephone: Home ________________________Office: ________________________Extension___ _______________________
Marital Status: ________________________ Name of Spouse (if applicable) __________________________________________
Sex: _____________________ No. of Children _____________________ Total No. of Dependents________________________
Date of Birth _________________________ Place of Birth ________________________________________________________
U.S. Citizen Yes _____
No ______ Social Security Number_____________________________________________________
2. TYPE OF TRAINING DESIRED
A. For graduating medical students seeking a continuum of training with first year spent at the University of Florida in Gainesville or
University Medical Center in Jacksonville.
________ Four-year program (one year clinical base, two years of clinical anesthesia training including basic anesthesia and
subspecialty anesthesia training, and one year of advanced anesthesia training which may be the advanced clinical track,
subspecialty clinical track or clinical scientist track).
B. For those who will have completed at least one year of postdoctoral training, e.g., internship or clinical residency in another
specialty before enrollment in our program:
________ Three-year program (two years of clinical anesthesia training including basic anesthesia and subspecialty anesthesia training, and one year of advanced anesthesia training which may be the advanced clinical track, subspecialty clinical track or
clinical scientist track).
_______ Other: __________________________________________________________________________________________
C. Post residency:
1) Research Fellowship
_______ 1 year
_______ 2 years
2) Clinical Fellowship_______________________________________________________________________ Subspecialty Area
_______ 1 year
_______ 2 years
3. LICENSURE ELIGIBILITY REQUIREMENTS
If you wish 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.
A. Qualifying Examinations
United States Medical Licensing Examination: Step1 _______________ Step 2________________ Step 3 ________________
National Boards: Part I Score____________________________________ Part II Score ________________________________
Part III Score _______________________________ Number_______________________________ Date ___________________
FLEX: State ____________________________________________ Date ___________________________________________
B. Licensure
State of Licensure
Date
Number
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
4. EDUCATION AND EXPERIENCE
Premedical College
Location
_____________________________________________________________________Dates ___________
____________________________________________________________________________ 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.
From/To
Activity
Place
Degree, If any
Program Director
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Membership in professional societies and others ________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5. MILITARY OBLIGATIONS
In reserves?_______ If yes, what branch? _____________________ Dates of Commitment ____________________________
6. LETTERS OF REFERENCE
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.
List below the names of all your references and have them write directly to us.
1. _____________________________________________________________________________________________________
Name
Address
City
State
Zip
2. _____________________________________________________________________________________________ ________
Name
Address
City
State
Zip
3. _____________________________________________________________________________________________________
Name
Address
City
State
Zip
Others: _________________________________________________________________________________________________
________________________________________________________________________________________________________
7. CITIZENSHIP (Complete if applicable)
IF A NATURALIZED CITIZEN:
Naturalization Certificate Number __________________________________________
Location ___________________________________ Date _____________________
IF NOT A U.S. CITIZEN:
Immigrants
Alien Registration Card No_______________________________
Expiration Date ____________________________
Non-Immigrant Aliens
Visa Number ___________________________________________ Type of Visa _______________________________
Expiration Date _________________________________________ Nationality ________________________________
Refugees
If you do not have an alien registration card or a visa, please send us a copy of the card attached to you passport by the
Immigration Service and complete the section below:
Country that issued your passport _______________________________________________________________________
Passport No. ______________________________________ 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, Country __________________________ Province ________________________ Date ________________________
International Medical Graduates who are not native American English speakers MUST complete the Test of English for International
Communication (TOEIC). The TOEIC is a written and verbal examination that tests your ability to function in an English-speaking
environment. The exam requirement may be waived by the program director if you have been raised or spent significant time in a
country where English is the primary language and received your medical training in English. Otherwise, the TOEIC exam is a MUST
and the results MUST be available prior to any consideration for listing in the match program. We do not advise signing up for the
examination until your application is determined to be competitive. The TOEIC examination results do not have to be available to be
considered for an interview, but must be available to be considered for the matching program. You must receive a score of 430 or
higher on both the Listening and Reading Sections of this examination, and the results must be available prior to February 1 st in order
to be included on our rank order list for the National Resident Matching Program.
8. PLEASE WRITE A BRIEF PARAGRAPH ABOUT YOUR GOALS AS A FUTURE ANESTHESIOLOGIST
ENCLOSE WITH THIS APPLICATION:
Recent Photograph (Passport Type)
If Applicable:
Copy of ECFMG and VQE certificate
Copy of Visa (for Non-Immigrant Alien)
Copy Alien registration Card
(for Immigrant Non-Citizen)
MAIL APPLICATION, ENCLOSURES AND
LETTERS OF REFERENCE TO:
Tammy Euliano, M.D.
Associate Professor & Program Director of Anesthesiology
Department of Anesthesiology
University of Florida College of Medicine
Health Science Center
P.O. Box 100254 JHMHC
Gainesville, FL 32610-0254
___________________________________________________
Signature of Applicant
EQUAL EMPLOYMENT OPPORTUNITY INSTITUTION