* Denotes Required Field
First Name*
Last Name*
Middle Initial
Street Address*
City*
State*
Country*
Zip Code*
Daytime Telephone
Home Telephone*
Email Address*
Place of Birth*
City
State or Province
Country
Country of Citizenship*

If NOT a U.S. Citizen, ECFMG Certification? No Yes
Date of ECFMG Certificate (mm/dd/yyyy)
ECFMG Certificate Number
Please indicate type of Visa to be held while at Boston Children's Hospital

Medical Licensure: Please list all licenses held.*

Massachusetts

None
Limited License
    Sponsoring Institution:
    Date of Expiration: (mm/dd/yyyy)
Permanent License
    Number
    Date of Licensure: (mm/dd/yyyy)
    Date of Expiration: (mm/dd/yyyy)
Other States

State Number Date of Licensure (mm/dd/yyyy) Date of Expiration (mm/dd/yyyy)


Examinations:

Please enter your scores for USMLE Steps 1, 2 and 3 or COMLEX Parts 1, 2 and 3, and completed In-Training Exams (CA-2 In-Training Exam scores should be submitted when received) as applicable.

None
Exam Date (mm/yyyy) Score  
Pass  Fail  N/A
Pass  Fail  N/A
Pass  Fail  N/A
Pass  Fail  N/A


Please indicate the type of fellowship sought:*

Pediatric Cardiac Anesthesia
1 Year (Only Offering)
Application and letters of recommendation to Kirsten C. Odegard, MD c/o Anne Bertolini
 
Pediatric Pain Management
1 Year
Application and letters of recommendation to Christine D. Greco, MD c/o Marybeth Sweeney
 
Pediatric Regional Anesthesiology
1 Year
Application and letters of recommendation to Karen Boretsky, M.D.
Preferred date for beginning fellowship*
PGY at that date*

Please list all educational, clinical, and research appointments, beginning with your college education.

FROM
Month/Year
TO
Month/Year
INSTITUTION POSITION or
DEGREE EARNED

Please explain any gaps, using this field, if necessary:


Has your medical license ever been suspended/revoked/voluntarily terminated?*

Yes  No
Reason:


Have you ever been named in a malpractice case?*

Yes  No
Reason:


Is there anything in your past history that would limit your ability to be licensed or to receive hospital privileges? :*

Yes  No
Reason:


Have you ever been convicted of a felony?*

Yes  No
Reason:


Please list the names of three people who will write letters of reference on your behalf. One letter of recommendation must be from your Department Chairman or Program Director; please indicate which of the recommenders listed is your Department Chairman or Program Director by adding an asterisk (*) after their name.

Name1*  
Title1*  
Name2*  
Title2*  
Name3*  
Title3*  


Please attach a current copy of your curriculum vitae:*

(.doc, .docx and .pdf files only)
 
Please attach a copy of your USMLE/COMLEX and In-Training Exam score transcripts.

If you do not include your score transcripts with this form, they will be requested from you after your application has been processed.


(.doc, .docx and .pdf files only)

(.doc, .docx and .pdf files only)

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