INTERNAL MEDICINE
GASTROENTEROLOGY FELLOWSHIP PROGRAM
EAST TENNESSEE STATE UNIVERSITY
JAMES H. QUILLEN COLLEGE OF MEDICINE
Name:
(Last)
(First)
(Middle)
Home Address (Current):
Social Security #:
Place and Date of Birth:
Phone Number:(_____)_________________
E-mail:
Visa Status:________________________________
Permanent Address:___________________________________________________________________
USMLE Scores: Step 1________ Step 2_________ CS________ Step 3_________
MEDICAL SCHOOL
Institution Name and Location
Dates
INTERNSHIP/RESIDENCY TRAINING
Institution Name and Location
Dates
FELLOWSHIP TRAINING
Institution Name and Location
Dates
RESEARCH EXPERIENCE INCLUDING PUBLICATIONS AND PRESENTATIONS
Institution Name and Location
Dates
OTHER EXPERIENCE
Practice, military service, etc.
Dates
MEDICAL LICENSES
State of Licensure
Certificate Number
LETTERS OF REFERENCE
Including one from your current/most recent program director and two from faculty members you
worked with during your internship and/or residency.
Name and Title
Institution or Address
Your application consists of this form, your personal statement discussing your interest in
Gastroenterology Fellowship including your ultimate professional objectives, ECFMG Certificate
(if applicable), copy of Medical School Diploma, three letters of reference, and your curriculum
vitae with a current photograph.
Please return your application to:
Mark Young, MD
Program Director
GI Fellowship Program
East Tennessee State University
Box 70622
Johnson City, TN 37614
(423) 439-6362
I certify that the information included on this document is accurate and correct.
_________________________________
Signature
_______________
Date
East Tennessee State University provides equal opportunity in education without regard to race, color,
creed, religion, national origin, sex, sexual orientation, age, marital status, disability, or status as a
disabled veteran or Vietnam era veteran in accordance with University policy and applicable federal and
state statutes and regulations.