OFFICE OF ACADEMIC AFFAIRS
HOUSE STAFF INITIAL APPLICATION (Revised 10/2010)
Resident/Fellow Last name:
SS#:
Date of Birth:
/
/
First:
Middle:
Place of Birth:
Gender:
Program Name:
Male
Female
Department Fund #:
Country of Citizenship:
USA -or-
Other (please
Work Authorization:
Visa Status (specify type – J1 or H1B):
specify):
Expiration Date:
Present Address:
Home Phone #: (
/
/
City:
)
-
Cell/Mobile #: (
Present Address:
Permanent Home Phone #: (
)
-
Degree:
Zip:
2nd year
Graduation Date:
/
ACADEMIC YEAR FOR WHICH YOU ARE APPLYING
1st year
State:
Permanent Cell/Mobile #: (
Medical School:
TRAINING LEVEL:
Zip:
Email Address:
City:
)
State:
3rd year
/
)
-
/
/
4th year
5th year
6th year
7TH year
SECTION I. Contains the programs sponsored by one of the hospitals listed below. The training in these programs occurs
primarily at the sponsoring institution. There may also be training taking place at other System facilities through structured
rotations. Please select the sponsoring hospital of your choice and then indicate to which program at that hospital you are
applying.
Facility: (check one)
NSUH
LIJ
Glen Cove
Forest Hills
Southside
PATHOLOGY
CYTOPATHOLOGY
DENTAL MEDICINE
INTERNAL MEDICINE
(Continued)
GEN. PRACTICE DENTISTRY
Hospice & Palliative Care
Oral & Maxillofacial Surgery
Interventional Cardiology
Oral & Maxillofacial Pathology
Nephrology
Pediatric Dentistry
Pulmonary/Critical Care
Rheumatology
EMERGENCY MEDICINE
Sleep Medicine
Emergency Med.*
EM/Internal Med.
NEUROLOGY
Toxicology
Clinical Neurophysiology
Sports Medicine
Movement Disorders
Family Practice Medicine
NEUROSURGERY
INTERNAL MEDICINE
Cardiology
OBSTETRICS/GYNECOLOGY*
Endocrinology
MATERNAL & FETAL MED
Gastroenterology
UROGYNECOLOGY
General Internal Medicine*
Geriatric Medicine
ORTHOPAEDIC SURGERY
Hem/Oncology
PEDIATRICS
Allergy/Immunology
Child Neurology
Dev/Behavioral
Plainview
Lenox Hill
Cardiothoracic Surgery
SURGERY
Podiatry
Pediatric
Laparoscopic
Critical Care
PHYSICAL MEDICINE &
REHABILITATION
UROLOGY
ADULT UROLOGY
PEDIATRIC UROLOGY
PSYCHIATRY
Consultation and Liaison
Geriatric Psychiatry
Addiction Psychiatry
ENDOUROLOGY
NEUROUROLOGY
RADIOLOGY, DIAGNOSTIC
Interventional/Vascular
Neuroradiology
Pediatric Radiology
Body Imaging
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Section II - Contains a list of merged programs. Training in these programs is conducted equally between the LIJ and NSUH
campuses. There may also be some training occurring at other System facilities through structured rotations. Please indicate to which
of the merged program you are applying.
Facility: (check one)
NEUROLOGY
NSUH
LIJ
Glen Cove
Forest Hills
Southside
Plainview
PEDIATRICS
PEDIATRICS (CONTINUED)
SURGERY
Adolescent Med.
Hematology/Oncology
Colon Rectal
Cardiology
Infectious Diseases
General Surgery*
OPHTHALMOLOGY
Critical Care Med.
Neonatal-Perinatal Med.
Vascular Surgery
Emergency Medicine
Rheumatology
PATHOLOGY
ANATOMICAL&CLINICAL Endocrinology
Gastroenterology &Nutrition PSYCHIATRY
General Pediatrics*
ADULT PSYCHIATRY
Child & Adolescent
Lenox Hill
RADIOLOGY
Nuclear Medicine,Special
Competence
*PGY1 positions are offered through the NRMP and are Categorical
UNIVERSITY EDUCATION
MEDICAL / DENTAL SCHOOL (S) (List exact name of all school attended, dates must include day, month and year)
Name:
Address:
Degree:
City:
Name:
Address:
Date From:
/
/
To:
City:
Date From:
/
/
/
Zip:
State:
Degree:
/
/
/
To:
State:
Zip:
Honors, Scholastic Achievement:
UNDERGRADUATE/GRADUATE SCHOOL (S) (List exact name of school (s), dates must include day, month and year
Name:
Address:
Degree:
City:
Name:
Address:
/
/
To:
State:
Degree:
City:
Date From:
Date From:
State:
/
/
/
/
Zip:
/
/
To:
Zip:
Honors, Scholastic Achievement:
2
HOSPITAL EXPERIENCE (Please PRINT/TYPE exact name of institution and give complete addresses, you must include
month and year of participation and PGY levels completed, please attach a chronological history detailing your academic and work
history, all time gapes must be explained)
1-Hospital
Program
Address:
City:
PGY Level:
1 2 3
5 6 7
Position:
2-Hospital
State:
4
8
Zip:
Date(s) From:
/
/
To:
/
/
/
/
Program
Address:
City:
State:
PGY Level:
1 2 3
5 6 7
Position:
3- Hospital
Zip:
Date(s) From:
4
8
/
/
To:
Program
Address:
City:
State:
PGY Level:
1 2 3
5 6 7
Position:
4
8
Date(s)From:
Zip:
/
/
To:
/
/
OTHER EMPLOYMENT:
1-Name of Institution:
Address:
Date of employment: Date(s) From:
Did you leave in good standing?
Job Title
/
Yes or
/
City:
To:
/
State:
Zip:
State:
Zip:
State:
Zip:
/
No
If No please explain
2-Name of Institution
Job Title
Address:
Date of employment: Date(s) From:
Did you leave in good standing?
City:
/
Yes or
/
To:
/
/
No
If No please explain
3-Name of Institution
Address:
Job Title
City:
3
Date of employment: Date(s) From:
Did you leave in good standing?
/
/
To:
Yes or
No
USMLE
Dates
/
ECFMG
Cert #:
FMGEMS
Dates
/
/
If No please explain
EXAMINATIONS / LICENSURE
/
/
/
S
core/Parts I
IICK
Expiration date:
/
Score / Parts I
ICS
/
II
III
Other
State Licensure
Dates
/
State Licensure
Dates
/
/
Number
/
Number
PUBLICATIONS / RESEARCH EXPERIENCE
Current project: updating a review of seizures and epilepsy in cancer patients; specifically, examining interactions between
chemotherapy agents and newer antiepileptic drugs.
SPECIALTY INTEREST / INTEREST IN NORTH SHORE-LONG ISLAND HEALTH SYSTEM. Please indicate how you
learned about the NSLIJHS program and what your future interests may be.
At Montefiore, our neurology residents rotate with LIJ neurology residents on the consult service. I have really enjoyed working
with them, and from them learned about the excellent teaching and training at the LIJ neurophysiology fellowship.
LETTERS OF RECOMMENDATION / MAILING INSTRUCTIONS
You must complete this application in duplicate and forward one copy to the Chairman of the Department or Training Program
Director to which you are applying at the North Shore-LIJ Health System. Submit the second copy to the Dean’s Office at your
school. YOUR DEAN’S LETTER, TRANSCRIPT AND ALL LETTERS OF RECOMMENDATION MUST BE ADDRESSED TO THE
CHAIRMAN OF THE DEPARTMENT OR TRAINING PROGRAM DIRECTOR TO WHICH YOU ARE APPLYING. If you wish, you may
include a brief biographical sketch. (Applicants for Pediatrics, please see special instructions in Chairmen’s letter.)
The policy of the Health System requires all prospective House Staff Officers undergo a toxicology screen prior to the
commencement of their training. All offers for such training are conditional upon satisfactorily passing both the toxicology
screen and a medical examination.
To the best of my knowledge, all of the above information is correct and true, and no such attempt has been made to conceal
pertinent information. I authorize my former employers, schools and personal references to provide any information they may have
regarding me, whether or not it is on their records. I hereby release them and their company and/or institutions from any and all
liability for divulging same. I understand that if any information given by me in this application is false or misleading I will be
subject to immediate dismissal, and I agree to hold the Health System and its agents blameless in that event.
Signature
/
Date
/
North Shore-LIJ Health System is an equal opportunity employer. Federal, State and local laws prohibit discrimination based upon race, color,
sex, national origin, age, religion, sexual preference or handicap.
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