Emergency Medical Services Fellowship Application and Document Upload Portal

General Information

Last Name

First Name

Date of Birth

Mailing Address

City

State

ZIP Code

Contact Phone Number

Email Address

Education Information

	School Name	Dates Attended	Degree
Undergraduate
Graduate
Medical School

Graduate Medical Education Training

	Program Name	Program Director	Dates in Training	Specialty
Internship
Residency
Fellowship

Specialty Board Certification (if applicable)

Board

Date Certified

Career Goals

Career Goals: Briefly describe your professional career goals. Include any relevant information or experiences that support your application.

Career Goals: Upload additional pages if needed

Required Documentation

The following documents must be submitted with your application.

Curriculum vitae

Personal Statement

Three letters of recommendation are required. One must be from your current program director (if applicable), confirming that you are in good standing and expected to graduate prior to the start of the residency/fellowship. At least one letter must be from an EMS medical director or a practicing EMS physician.

Letter of Recommendation 1

Letter of Recommendation 2

Letter of Recommendation 3

USMLE and/or COMLEX board scores

MPSE (Dean's letter)

ECFMG certificate (if applicable)

Documentation of Prior Training (if applicable)

If you have completed a residency, please provide a certificate of completion. If you are currently in training, please include a letter of recommendation from your program director (see above)

I certify that the information in this application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for a position or may constitute cause for termination from the program.

Full Name

Date

Contact Information