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.