COMPLETING THE APPLICATION FOR FELLOWSHIP
Please type or print legibly in black ink.
Honors/Awards (Item 7, Page 1): List all honors/awards, including membership in honor
societies such as AOA. Specify the basis for any special recognition (i.e., academic
performance, special accomplishments, leadership, research, community service, etc.)
Personal Statement (Item 11, Page 3) The Personal Statement provides you with the
opportunity to communicate your professional interests and achievements with regard to
research experience and training, special projects, and professional accomplishments.
Bibliographic references should be provided for all published papers. Program Directors are
also interested in your future plans as defined by your specialty goal and the number of years
you intend to devote to graduate medical education.
You may also wish to describe your personal interests, activities, and circumstances. As
transcripts of your academic accomplishments are most likely to be required, and interruption
in your medical education should be explained in the Personal Statement.
Permanent Address and Telephone Number (Item 18, Page 4): Enter the name, address,
and telephone number of an individual through whom you can always be contacted (i.e.,
parent, relative, close friend, etc.).
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.
References (Item 23, Page 5): We require the Residency Program Director’s or the
Department Chairman’s letter as a standard reference. We require a minimum of two
additional evaluations. References should be from faculty members or physicians who are
familiar with your credentials and are in a position to comment on your suitability for the
position you seek.
SUBMITTING THE APPLICATION FOR FELLOWSHIP
The deadline for submitting application material is November 30th. Application submissions
must include a personal statement, fellowship application, updated curriculum vitae, and
three letters of reference including one from the program director or department chairman.
These should be mailed to:
Administrative Manager of Academics
Department of Physical Medicine and Rehabilitation
Attention: TBI/Neurological Rehabilitation Fellowship Application
Spaulding Rehabilitation Hospital
300 First Avenue
Charlestown, MA 02129
Rev. 10/07/09
PAGE ONE
APPLICATION FOR FELLOWSHIP
HARVARD MEDICAL SCHOOL/SPAULDING REHABILITATION HOSPITAL
TBI/Neurological Rehabilitation Fellowship Application
NAME:
(LAST)
(FIRST)
(MIDDLE)
POSITION BEGINNING IN:
(MONTH)
1. E-MAIL:
(YEAR)
2. SOCIAL SECURITY NUMBER:
RESIDENCY EDUCATION
3. MEDICAL SCHOOL or INSTITUTION
(NAME)
(CITY)
(STATE/COUNTRY)
4. PM&R RESIDENCY PROGRAM:
5. DATE OF COMPLETION:
6. PROGRAM DIRECTOR:
7. HONORS/AWARDS:
MEDICAL EDUCATION
8. MEDICAL SCHOOL
NAME:
CITY:
STATE/COUNTRY:
GRADUATE EDUCATION
9. GRADUATE SCHOOL(S)
A. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
GRADUATE DEGREE (IF ANY):
AREA OF STUDY:
B. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
GRADUATE DEGREE (IF ANY):
AREA OF STUDY:
Rev. 10/07/09
PAGE TWO
APPLICATION FOR FELLOWSHIP
UNDERGRADUATE EDUCATION
10. UNDERGRADUATE COLLEGE(S)
A. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
DEGREE (IF ANY):
MAJOR:
B. NAME (CITY/STATE):
FROM (MO/YR):
TO (MO/YR):
DEGREE (IF ANY):
MAJOR:
Rev. 10/07/09
PAGE THREE
APPLICATION FOR FELLOWSHIP
11. PERSONAL STATEMENT (SEE INSTRUCTIONS. USE ADDITIONAL SHEET IF NECESSARY)
12. 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 __________________________
(MONTH/YEAR)
NUMBER OF YEARS COMMITTED
Rev. 10/07/09

PAGE FOUR
APPLICATION FOR FELLOWSHIP
13. ECFMG Registration (if applicable):_____________________________________
14. PRESENT ADDRESS
______________________________________________________________________
(STREET)
______________________________________________________________________
(CITY) (STATE) (ZIP)
15. PRESENT PHONE NUMBERS:
DAY:__________________________________________________________________
EVENING:
16. VISA STATUS (IF APPLICABLE)
PERMANENT
TEMPORARY – SPECIFY
J-1
H-1
17. CITIZENSHIP
U.S. OTHER
ATTACH RECENT
PHOTOGRAPH
(SEE INSTRUCTIONS)
18. PERMANENT ADDRESS:
______________________________________________________________________
C/O (NAME OF PERSON THROUGH WHOM I CAN ALWAYS BE CONTACTED)
______________________________________________________________________
(STREET)
______________________________________________________________________
(CITY) (STATE) (ZIP)
Rev. 10/07/09
PAGE FIVE
APPLICATION FOR FELLOWSHIP
19. I plan to take the examinations checked below before I begin the Graduate Medical Education program for
which I am now applying:
USMLE, STEP 1 USMLE, STEP 11 USMLE, STEP 111
20. I have already passed the examinations checked below on the dates indicated:
NMBE, PART 1______ NMBE, PART 11______ NMBE, PART 1______
(DATE)
(DATE)
(DATE)
USMLE, STEP 1______ USMLE, STEP 11____ USMLE, STEP 111______
(DATE)
FLEX: ______
(DATE)
(DATE)
______________________
(State[s] of Licensure)
(DATE)
21. LIST ANY ADDITIONAL EXAMINATIONS PASSED (FMGEMS, DAY 1; FMGEMS, DAY 2; VQE, DAY
1; VQE, DAY 2; ECFMG MEDICAL SCIENCE EXAM);
22. I have read and I understand the instructions for the completion of this application. I certify that the
information submitted on these application materials is complete and correct to the best of my knowledge: I
understand that any false or missing information may disqualify me for this position.
SIGNATURE OF APPLICANT:_____________________________DATE:___________________
NOTE: THE SIGNATURE AND DATE ON EACH APPLICATION PAGE MUST BE ORIGINAL.
23. LETTERS OF REFERENCE, IN ADDITION TO RESIDENCY PROGRAM DIRECTOR’S LETTER,
HAVE BEEN REQUESTED FROM THE FOLLOWING INDIVIDUALS:
A. NAME AND TITLE:
INSTITUTION:
ADDRESS:
B. NAME AND TITLE:
INSTITUTION:
ADDRESS:
C. NAME AND TITLE:
INSTITUTION:
ADDRESS:
I HEREBY WAIVE ACCESS TO THE ABOVE LETTERS AND
WILL SO INFORM THE AUTHORS.
24. (CHECK ONE)
I DESIRE ACCESS TO THE ABOVE LETTERS AND WILL SO
INFORM THE AUTHORS.
_____________________________
____________________
SIGNATURE
DATE
_______________________________
NAME OF APPLICANT -TYPE OR PRINT
NOTE: THE SIGNATURE AND DATE ON THIS STATEMENT MUST BE ORIGINAL.
Rev. 10/07/09