Adult Congenital Heart Program at Stanford
Fellowship Application
Fellowship Training Program - APPLICATION
Name (Last, First, Middle Initial)
Date of Application
Home Address (Street/P.O. Box, City, ST, Zip)
Work Address (Street/P.O. Box, City, ST, Zip)
Home Telephone
Work/Lab Telephone
Email Address
Your Dept.
Gender
Female
Work/Lab Fax
Birthdate (mm/dd/yy)
Male
Citizenship:
US Citizen
Foreign National of
Permanent Resident of US
___________________ (Country)
Education – After High School
(Indicate all academic and professional education.
For foreign degrees, give US equivalent.)
Name of Institution, Department
and Location
Baccalaureate Degree
Masters Degree
Medical Degree
Additional Doctorate Degree
Attendance
Mo/Yr
From
To
Degree(s) Received
Major Field
Minor Field
Degree
Grade Pt Ave
Mo/Yr
International Medical Graduate
1. If you are a graduate of an international medical school (except Canada), you are required to be certified
by the Educational Commission for Foreign Medical Graduates (ECFMG). Please provide a copy of your
ECFMG certificate.
2. If not a U.S. citizen, what type of visa will you hold while you are here?
3. Do you hold permanent immigrant status in the United States?
If yes, please attach a copy of green card or approval letter.
4. Are you currently in the United States on a Temporary Visa (i.e. J-1, H-1, F-1)?
If yes, attach a copy of your current DS-2019 (if applicable).
Medical Licensure and Examinations
State
Number
Expiration Date
Permanent
Limited
State
Number
Expiration Date
Permanent
Limited
State
Number
Expiration Date
Permanent
Limited
Research Experience:
Institution
Dept.
Dates
Advisor
Research Topic
Other Relevant Experience:
List all Academic Honors, including Fellowships and Scholarships (or append CV):
List all Publications (or append CV):
Date____________________ Signature __________________________________________________
INSTRUCTIONS: (Please type or print)
Application for clinical training is due by October 1, the year prior to start of training.
Materials must include:
1. Completed fellowship application
2. Curriculum vitae and bibliography
3. Statement of professional and investigative interests (limit: one page)
4. List of references from whom you are requesting letters
5. A small photograph
6. Three letters of recommendation mailed directly to Administrative Coordinator: one from
the Chief of your present service and two others most familiar with your medical career
and qualifications.
7. Medical School Transcript. A translation must be provided if in a language other than
English.
8. Copies of United States Medical Licensing Exam (USMLE) scores or Medical Council of
Canada (MCC) scores.
9. ECFMG Certificate if you are a graduate of medical school outside of the United States or
Canada.
Mail applications to:
Joyce Hages
870 Quarry Road,
Cardiovascular Medicine
Stanford, CA 94305
LICENSURE: California law requires that all fellows hold a state license or exemption from
licensure for graduates of foreign medical schools outside Canada or U.S. Territories. Those
who do not have such a license must take and pass the next examination following
commencement of service, or obtain licensure by reciprocity with National boards or another
state.
California’s minimum requirements are: Each applicant for licensure shall document
completion of “an allopathic medical curriculum in a medical school or schools which extend
over a period of at least four (4) academic years totaling at least thirty-six (36) months of
clinical rotations, including all core clinical rotations.” For further information write:
Licensing Division, California Board of Medical Quality Assurance, 1430 Howe Ave.
Sacramento, CA 95825.