ATC Fellowship Application Step 1 of 3 33% HiddenDATE SENT: Month Day Year Identifying InformationName* First Middle Last Email*Using your personal email address is highly recommended. Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Birth Date* Birth Place*City/State/Country Citizenship U.S. Canada Other Citizenship (if not US or Canada)* Visa (if not US)* ECFMG Number Please list any outside interests or hobbies.Are you currently a Resident member of the American Head and Neck Society?*All fellowship applicants are required to be an AHNS member or to have an AHNS Resident membership application submitted and in process before the Fellowship Match occurs. For AHNS Resident membership information, please contact the AHNS membership office at [email protected] or 310-437-0559 x 126. [Applicants who have completed their medical education outside of the US or Canada do not need to apply for AHNS membership.] Yes No I have already applied for membership and am awaiting acceptance. EducationDid you receive your medical training in the United States or Canada*If you are enrolled in a 4-5 year residency in the United States or Canada please answer YES to this question. Yes No International applicants complete an online AHNS Fellowship application form. International applicants pay only the $50 processing fee – you do NOT pay the $15 fee for each individual program. Upon the completion of the 2020 match process on July 1, 2019, your application will be distributed to the programs that wish to review international applicants. For more information on international applicant eligibility, please visit: https://www.ahns.info/residentfellow/fellowships/internationalPre-Medical Education*Please use the plus button to add more colleges/universities.College/University NameDegree ReceivedDate of GraduationCity, State Post Graduate Education*Please use the plus button to add more colleges/universities.College/University NameDegree ReceivedDate of GraduationCity, State Please upload your CV*Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.Residencies/FellowshipsOn the form below, please include, in chronological order, all residencies, fellowships, preceptorships, teaching appointments and postgraduate education. Please include ALL programs you attended, regardless of if you completed the program or not.How many residency/fellowship programs have you attended?*0123Residency/Fellowship 1Institution* HiddenProgram Director* HiddenInstitution Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type of Training (e.g. residency, etc)* Specialty* From* MM slash DD slash YYYY To* MM slash DD slash YYYY Was the program clinical or academic?* Clinical Academic Did you successfully complete the program?* Yes No Why were you not able to complete the program?*Residency/Fellowship 2Institution* Program Director* Institution Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type of Training (e.g. residency, etc)* Specialty* From* MM slash DD slash YYYY To* MM slash DD slash YYYY Was the program clinical or academic?* Clinical Academic Did you successfully complete the program?* Yes No Why were you not able to complete the program?*Residency/Fellowship 3Institution* Program Director* Institution Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Type of Training (e.g. residency, etc)* Specialty* From* MM slash DD slash YYYY To* MM slash DD slash YYYY Was the program clinical or academic?* Clinical Academic Did you successfully complete the program?* Yes No Why were you not able to complete the program?*Peer ReferencesPeer References*Please list your references below and upload any letters you have received. Letters of reference can be submitted through this form OR sent directly to JJ Jackman (AHNS Associate Executive Director) in the administrative office at [email protected]First and Last Name of Reference 1 of 3 Letters of Reference Drop files here or Select files Accepted file types: doc, pdf, docx, txt, Max. file size: 64 MB, Max. files: 1. 2 of 3 Letters of Reference Drop files here or Select files Accepted file types: doc, pdf, docx, txt, Max. file size: 64 MB, Max. files: 1. 3 of 3 Letters of Reference Drop files here or Select files Accepted file types: doc, pdf, docx, txt, Max. file size: 64 MB, Max. files: 1. Additional Letter of Reference (OPTIONAL) Drop files here or Select files Accepted file types: doc, pdf, docx, txt, Max. file size: 64 MB, Max. files: 1. Additional Letter of Reference (OPTIONAL) Drop files here or Select files Accepted file types: doc, pdf, docx, txt, Max. file size: 64 MB, Max. files: 1. Board Certification* Yes No License Number* State* Expiration* Please list all honors and awards.In-Training Exam Score (all years)First Second Third Fourth Professional LiabilityHave there been, or are there currently pending, any malpractice claims, suits, settlements or arbitration proceedings involving your professional practice?* Yes No Please provide a list and status of each instance.*Disciplinary ActionsHave any of the following ever been, or are currently in the process of being denied, revoked, suspended, reduced, placed on probation, not renewed or voluntarily relinquished?Please check off all that apply. Medical license in any state Other professional registration / license DEA registration Academic appointment Membership on any hospital medical staff Clinical privileges Prerogative / rights on any medical staff Other institutional affiliation or status threat Professional society membership or fellowship / Board certification Professional office Any other type of professional sanction Professional liability insurance Have there been any felony criminal charges brought against you in the last 5 years?* Yes No Have you been convicted of any crimes?* Yes No Please explain any "yes" answers.*Additional AttachmentsPlease upload your personal statement.*Please limit your statement to approximately 800 words - not to exceed 1 page.Accepted file types: doc, pdf, docx, Max. file size: 64 MB.Upload a recent photo.*Accepted file types: jpg, gif, png, pdf, tif, bmp, Max. file size: 64 MB. Application Fee* Price: Fellowships Participating in the FY2023 MatchPlease select all programs you would like to receive your application. Each additional program is a $15 charge. AdventHealth Augusta University Case Western/UH Cleveland Med Ctr - H&N Cleveland Clinic - H&N Emory University - H&N Henry Ford Medical Group Icahn SOM at Mount Sinai - H&N Indiana University - H&N Johns Hopkins - H&N Johns Hopkins - Endocrine MD Anderson - H&N Mass Eye & Ear - H&N Mass Eye & Ear - Endocrine Medical Univ of SC - H&N Memorial Sloan Kettering CC - H&N Mount Sinai Beth Israel - H&N Moffitt Cancer Center - H&N Nebraska Methodist Hospital - H&N New York University Langone Health – H&N Northwestern University - H&N Ohio State University - H&N Oregon Health & Science U - H&N Penn State University Roswell Park CC - H&N Stanford Univ SOM - H&N Stanford Univ SOM - Endocrine Thomas Jefferson U - H&N University of Alabama-Birmingham - H&N University of Alberta Hospital - H&N University of CA-Davis - H&N University of CA-San Francisco - H&N University of Cincinnati - H&N University of Florida - H&N University of Iowa - H&N University of Kansas - H&N University of Miami - H&N University of Michigan - H&N University of Oklahoma – H&N UNC-Chapel Hill - H&N University of Pennsylvania - H&N University of Pittsburgh Med Ctr - H&N University of Toronto - H&N University of Washington - H&N University of Wisconsin - H&N UT Southwestern Medical Center Vanderbilt University Med Ctr - H&N Washington University @ St Louis - H&N Wayne State University - H&N Total $0.00 Credit Card*If you are unable to pay the application fee with a credit card, please contact AHNS Administrative Coordinator Ochun Farlice at [email protected] to make other payment arrangements. American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name By submitting this application, I hereby certify that, to the best of my knowledge and belief, I have no physical or mental illness or mental defect that interferes with my professional appointment. All information submitted by me in this application is true and accurate to the best of my knowledge and belief. I agree to be a participant in the American Head and Neck Society 2023 match. I agree to submit my match list prior to the deadline of July 1, 2022. If I wish to withdraw from the match, I must do so prior to July 1, 2022, by contacting the AHNS office. CommentsThis field is for validation purposes and should be left unchanged. Share:FacebookTwitterLinkedIn