For General Internal Medicine Fellowship Program applicants only.

AREA OF INTEREST:




PERSONAL DATA
Last name: First name: Middle initial:
Social Security number: - - Check here if you don't have a Social Security number

Permanent address:
Street: City:
State: Zip:

Current address:
Street: City:
State: Zip: E-mail:
Home phone: () - Cell phone: () -

Your responses to questions marked with * are VOLUNTARY, will be kept confidential, and will not be used to deny access or admission. The information will, however, assist the University in providing data to demonstrate compliance with federal regulations.

*Date of birth (mm/dd/yyyy): *Gender:


*Ethnic group: Are you Hispanic or Latino?

*Race:


Please indicate if other:

Citizenship information:
Place of birth: US citizen:

If you are not a citizen, please answer the following questions regarding immigrant status and visa type.

US immigrant/permanent alien: Nonimmigrant student/exchange visitor
Visa type:


EDUCATIONAL BACKGROUND

Undergraduate education:
School: Degree: Year of graduation:
Other advanced degrees:
School: Degree: Year of graduation:
Medical education:
School: Degree: Year of graduation:

Graduate education:

Program 1
Program: Date completed: /
Supervisor's first name:   Last name:

Program 2
Program: Date completed: /
Supervisor's first name:   Last name:

Program 3
Program: Date completed: /
Supervisor's first name:   Last name:
Please list any honors you have received:
AOA membership
Medical licensure:
State:   License number:   Year:


REFERENCES

Please list the names of three members of the medical faculty whom you have requested to send reference letters. One should be the chair of the Department of Medicine or the director of the residency program.


First name: Middle initial: Last name: Title:
Organization: Phone: () -
Street: City: State:
Zip:
First name: Middle initial: Last name: Title:
Organization: Phone: () -
Street: City: State:
Zip:
First name: Middle initial: Last name: Title:
Organization: Phone: () -
Street: City: State:
Zip:

SUPPORTING DOCUMENTS

(ALL FILES MUST BE FILE TYPES .DOC, .DOCX, OR .PDF)

Please upload the following supporting documents that need to accompany your application.

Personal Statement:
Personal Statement Guidelines: Be sure to include your rational for pursuing the fellowship as well as a description of your future career goals.

CV:

Scanned copies of your Step 1, 2, and 3 USMLE score reports:


LETTERS OF RECOMMENDATION

NOTE: To complete your application, please direct your letter writers to send their letters of recommendation to the address below. Three letters of recommendation (one of which must be from your department chair or program director) are required.

General Internal Medicine
Fellowship Training Program
ATTN: Annette Sampson
University of Pittsburgh
General Internal Medicine Fellowship Coordinator
Department of Medicine, Office of Education
UPMC Montefiore Hospital, N715
200 Lothrop Street, Pittsburgh, PA 15213
sampsonam2@upmc.edu

Phone: 412-683-7647; Fax: 412-692-4944

If you have waived your right to see your letters of recommendation, please upload a signed statement on official letterhead indicating this.


SIGNATURE

Electronic applications do not need to be signed. Checking the box below is considered equivalent to your signature.

I certify that the information provided on this application form and supporting documentation is accurate and correct. I understand that providing false and misleading information is just cause for disqualification for admission or dismissal from the University of Pittsburgh. If enrolled as a student, I agree to abide by the rules and regulations set forth by the University of Pittsburgh as they are at the time of my admission or as they may change during my continuance as a student.

The University of Pittsburgh values equality of opportunity, human dignity, and racial/ethnic and cultural diversity. Accordingly, the University prohibits and will not engage in discrimination or harassment on the basis of race, color, religion, national origin, ancestry, sex, age, marital status, familial status, sexual orientation, disability, or status as a disabled veteran or a veteran of the Vietnam era.