UCSD PAIN MEDICINE
FELLOWSHIP APPLICATION
INSTRUCTIONS FOR THE UNIVERSAL APPLICATION FOR PAIN MEDICINE FELLOWSHIP:
PLEASE READ CAREFULLY
REQUIRED DOCUMENTS
IN SEPARATE DOCUMENTS, PLEASE ATTACH YOUR MOST RECENT CURRICULUM VITAE
and a PERSONAL STATEMENT.
1.
Curriculum Vitae: Your curriculum vitae should include but not be limited to the following:
a.
Additional Research Work
b.
Publications and Publication Contributions (i.e., abstracts, manuscripts, peerreviewed articles, and/or presentations),
c.
Professional Memberships, Attendance at Professional Society Meetings (if
applicable), Community Services, Certifications, Honors, Licenses, etc.
2.
Personal Statement: Please include additional information that was not included in your
curriculum vitae. Please also provide information concerning your future medical short and
long terms goals.
3.
Current License: Please include a copy of your current medical license. This may be a temporary residency
license.
4.
Optional Additional Information: The following Licenses are required if accepted into the UCSD Pain Medicine
fellowship. Please include copies of the following licenses if you currently have them.
a.
California State Medical License
b.
ACLS/BLS
c.
DEA
SUBMITTING THE UNIVERSAL APPLICATION FOR PAIN MEDICINE FELLOWSHIP
Mail this application along with the above mentioned documentation to:
Mark S. Wallace, MD, Fellowship Program Director
Attention: Debra Kerrigan, Fellowship Coordinator
UCSD Anesthesiology Center for Pain Medicine Fellowship Program
9300 Campus Point Drive, MC 0924
La Jolla, CA 92037-1300
painfellowship@ucsd.edu
You should submit (via US mail ) all pages of the Universal Application for Pain Medicine Fellowship,
with original signatures, to each program to which you wish to apply. It is the applicant’s responsibility
to arrange to submit required supplementary materials (transcripts, letters of evaluation, etc.) by the
designated program's stated deadline.
APPLICATION FOR PAIN FELLOWSHIP - PAGE ONE
POSITION BEGINNING IN _______________________________________________________ (Month/Year)
1.
Name
Middle
Last
2. Social Security Number
First
3. Address: Street
4A. Home Telephone Number
5A. Preferred Email Address
City
State
4B. Cellular Telephone Number
Zip code
4C. Alternative Telephone Number
5B. Alternative Email Address
6. Name of Current Hospital / Institution
City
State
Zip code
Academic History
(Attach CV)
Premedical, Medical and Graduate Education
Location
Degree
Dates of Attendance
(a)
/
/
-
/
/
(b)
/
/
-
/
/
(c)
/
/
-
/
/
Previous Internship, Residency, and/or Fellowship Trainin g
8.
Institution
Location
Specialty
Dates of Attendance
/
/
-
/
/
(b)
/
/
-
/
/
(c)
/
/
-
/
/
(FIRST)
(a)
Research Experience (if applicable)
9.
Institution
Location
Dates of Attendance
(a)
/
/
-
/
/
(b)
/
/
-
/
/
(MIDDLE)
Principal
Investigator/
Other
NAME
Institution
(LAST)
7.
APPLICATION FOR PAIN FELLOWSHIP - PAGE TWO
10. PLEASE COMPLETE THE FOLLOWING CONCERNING ANY REVOCTIONS AND/OR DENIED PRIVILEDGES
Have you ever been denied a license and/or privileges?
Yes
If YES, please provide information concerning the incident (s):
No
________________________________________________________________
_____________________________________________________________________________________________________________________
CITIZENSHIP
11. CITIZENSHIP
U.S.
Other
12. VISA STATUS (IF APPLICABLE)
Permanent
(Specify) _____________
Temporary
Specify:
H1
J1
13. PERMANENT ADDRESS (C/O NAME OF PERSON THROUGH WHOM I CAN ALWAYS BE CONTACTED)
Street: _______________________________________________________________________________________________________
City: ______________________________________________
State: __________________
Zip Code: _______________________
14. PERMANENT TELEPHONE NUMBER : ___________________________________________________
15. SERVICE OBLIGATIONS (NATIONAL HEALTH SERVICE CORPS, ARMED FORCES SCHOLARSHIP, STATE PROGRAMS, ETC.)
I AM NOT REQUIRED TO FULFILL ANY SERVICE OBLIGATIONS
I AM COMMITTED TO FULFILL A SERVICE OBLIGATION BEGINNING
(MO /YR)
NUMBER OF YEARS COMMITTED
*ATTACH RECENT PHOTOGRAPH (OPTIONAL)
*Photograph: Most program directors request a photograph in order to associate a face with the "paper work". If you do not
submit one at this time, you should be prepared to provide one when you are interviewed.
APPLICATION FOR PAIN FELLOWSHIP - PAGE THREE
16. I have already passed the examinations checked below on the dates indicated:
USMLE, STEP I:
USMLE, STEP II:
(Date)
Actual Score
Actual Score
____________
COMLEX I:
17.
18.
(Date)
Actual Score
____________
COMLEX II:
(Date)
Actual Score
USMLE, STEP III:
(Date)
COMLEX III:
(Date)
Actual Score
____________
____________
(Date)
Actual Score
____________
____________
LIST SPECIALITIES (if applicable):
Board _____________________________________
Year Certified _________________ Exp.____/____
Board _____________________________________
Year Certified _________________ Exp.___ /____
LETTERS OF REFERENCE HAVE BEEN REQUESTED FROM THE FOLLOWING INDIVIDUALS:
(a) Name
Institution
Address
Title
Department
City, State, Zip Code
(b) Name
Institution
Address
Title
Department
City, State, Zip Code
(c) Name
Institution
Address
Title
Department
City, State, Zip Code
Deans Letter(s) (if applicable)
(d) Name
Institution
Address
Title
Department
City, State, Zip Code
19. Will you be available for appointment in July 1? (YES or NO) _________________________________________________
I have read and understand the instructions for the completion of this application. I certify that the information submitted
on this application is complete and correct to the best of my knowledge. I understand that any false or missing information
may disqualify me for this position.
NOTE: THE SIGNATURE AND DATE ON EACH APPLICATION MUST BE ORIGINAL.
Signature of Applicant:
Date: