APPLICATION
PEDIATRIC ENDOCRINOLOGY SUB-SPECIALTY RESIDENCY PROGRAM
CHILDREN’S HOSPITAL AND REGIONAL MEDICAL CENTER
Seattle, Washington
Date_____________________________________
Specify year to begin training: July, ___________
NAME_______________________________________________________
Last
First
Soc Security #_______-_______-_______
MI
PRESENT ADDRESS:
HOME ADDRESS:
________________________________________________
_____________________________________________
________________________________________________
_____________________________________________
________________________________________________
_____________________________________________
TELEPHONE:
Work_____________________________
Home________________________________________
Date & Place of Birth ______________________________
Email Address:_________________________________
Foreign medical school graduate Yes
No
ECFMG No.______________________ Type of Visa_____________________ Visa No._______________________
Premedical Education
College & Location
Major Area of Study
Dates Attended
Degree/Date Awarded
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medical Education
Medical School
Location
Dates Attended
Degree/Date Awarded
_______________________________________________________________________________________________________________________
Other graduate education (PhD, MPH, Other)
Internships, Residencies and Fellowships
Name of Hospital
Location
Specialty
Dates
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
USMLE Scores Step 1________
Step 2________
Are you licensed to practice medicine? Yes
No
License No._____________________________________
Step 3________
Which states______________________________________________
Expiration date____________________________________________
References
Please ask the Dean’s Office of your medical school to send a Dean’s letter of reference and a transcript of your medical school
record. Three letters of recommendation are required from faculty or professional staff of your medical school or residency program.
Additional recommendations are encouraged. List all names below.
Name and Title
Relationship
Institution, City, State
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Membership in Professional Societies___________________________________________________________________
Honors, Scholarships, Grants, etc_______________________________________________________________________
Publications________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Military Service and present status______________________________________________________________________
Yes answers to the following questions require written explanation on a separate sheet.
Positive responses do not necessarily preclude acceptance.
Have you been involved in a malpractice lawsuit or claim?
(Whether or not you were individually named as a defendant)
Yes
No
Have you ever been called before any entity for questioning concerning unprofessional conduct,
incompetence, negligence, unsafe practice, or mental or physical impairment?
Yes
No
If you have been licensed to practice medicine, has any such license ever been denied, revoked,
suspended or restricted?
Yes
No
If you have been licensed to practice medicine, has any such license ever been denied, revoked,
suspended or restricted?
Yes
No
Have you ever been addicted to, or treated for, addiction to a controlled substance, drug or chemical?
Yes
No
Have you ever used a prescription drug, including controlled substances, for other than therapeutic purposes?
Yes
No
Are you suffering from any disability or illness (mental or physical) which could affect your ability to fully
practice medicine?
Yes
No
Signature___________________________________________________________________Date___________________
Write a brief narrative discussing your interest in the field of Pediatric Endocrinology and your ultimate professional
objectives. Are you interested in an academic career in teaching and research, private practice, administration, or other
areas?
Send completed application to:
Patricia Fechner, M.D., Program Director
Pediatric Endocrinology, M/S A5902
Children’s Hospital and Regional Medical Center
PO Box 5371
4800 Sand Point Way NE
Seattle, Washington 98105
Phone (206) 987-5271 Fax (206) 987-2720
After the fellowship committee has reviewed your application, you will be contacted if you are to be
invited for an interview.