UT SOUTHWESTERN MEDICAL CENTER Department Application for ECFMG Sponsored J-1 Visa Applicant’s Name: _____________________________________________ _____________________________________ __________________________ Family Name First Name Start Date: __________________ Middle ECFMG #: ______________________________ ACGME Accredited Program # (If any): _________________________________________ Program Name: ___________________________________________________________________ Program Director: ________________________________________________________________ Resident? Fellow?: Primary Site of Activity Paid By: YES_______ NO ______ YES_______ ___UTSW 480316 NO ______ ___ PMH 480400 ___ VA 480290 UTSW ____ STIPEND _____ PGY _______ PGY _______ ___ UH ZALE 488034 PMH ____ or ACGME ACCREDITED? SALARY: $______________________________ ___CMC 480360 ___TSRHC 480341 ___ UH Clements 480103 CMC ____ Other Fund Source _____________________________________________ SALARY _____ YES ______ If Non-Accredited/Non Standard Program: NO ______ Name of Accredited Parent Program *: _______________________________________________________________________________________ Program Director of Accredited Program: ____________________________________________________________________________________ Educational Coordinator Contact Information: Name: _________________________________________________________________________ E-Mail: ________________________________________________________________________ Phone: _______________________________________ Mail Code: __________________________________ Federal Express Shipping Number __________________________________________ (for mail costs) OR you can use your Sub-Ledger for Mail costs UTSW Sub-Ledger #:_________________________________________________________ Dept. ID#: ___________________________________ * The Accredited Parent Program is the residency program usually considered a pre-requisite for completion of a non-standard fellowship, and may share resources, such as faculty and facilities, with the non-standard program.