Fellowship Application

Fellowship Training to Begin:
Name:

Present Address:

Home Telephone:

Work Telephone:

Work Address:
Social Security Number:
Birthdate:
Place of Birth:
Citizenship:
If not Citizen:
(Date of Entry into U.S.)
Type of Visa Held:
(Exchange Visitor, Immigrant, etc.)

EDUCATION:
(Including addresses for all institutions.)

College:

Dates Attended:
From To
Degree:

Address:
College 2:

Dates Attended:
From To
Degree:

Address:
Medical School:

Dates Attended:
From To
Degree:

Medical School Address:

If a foreign medical school graduate...
have you obtained certification from the Educational Commission for Foreign Medical Graduates?

Indicate exams passed:
Visa Qualifying Examination
Foreign Medical Graduate Exam in the Medical Sciences

TRAINING
INTERNSHIP
College:

Dates Attended:
From To
Degree:

Hospital:

Address:
College 2:

Dates Attended:
From To
Degree:

Hospital:

Address:

RESIDENCY:

College 1:

Dates Attended:
From To
Degree:

Hospital:

Address:
College 2:

Dates Attended:
From To
Degree

Hospital:

Address:

USMLE Scores

Step 1 Score:
Step 2 Score:
Step 3 Score:

Date:
Date:
Date:

MEMBERSHIP IN HONORARY OR PROFESSIONAL SOCIETIES,
PRIZES, AWARDS, FELLOWSHIPS, ETC. (Please include AOA membership.)

Medical License

State:
Date:
How Obtained:
(Examination, Reciprocity)
Are you a diplomate of National Board of Medical Examiners (U.S.)?
Date of Certification: 
Professional Goals and Career Plans:
Research Experience or Interest(s):

Today's Date:

The application will be sent to:

Aimee D. Garcia, M.D.
Baylor College of Medicine
Huffington Center on Aging
One Baylor Plaza, M320
Houston, TX 77030-3498