AHNS Fellowship Application

ATC – Fellowship Application

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DATE SENT:

Month

Day

Year

Identifying Information

Name*

First Middle Last

Email*

Please use a personal email address rather than an institutional email if possible for this application.

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date*

Birth Place*

City/State/Country

Citizenship

U.S.

Canada

Other

Citizenship (if not US or Canada)*

Visa (if not US)*

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

I have already applied for membership and am awaiting acceptance.

Education

Did you receive your medical training in the United States or Canada*

If you are enrolled in a 4-5 year ACGME accredited residency in the United States or Canada please answer YES to this question.

Yes

International applicants who completed their medical education outside the US or Canada will be considered “International Track” applicants and are required to have completed (or in the process of completing) a non ACGME-approved or non RCPSC-approved residency in Otolaryngology, General Surgery, or Plastic Surgery (Head and Neck Fellowships) and Otolaryngology and General Surgery (Head and Neck Endocrine Fellowships).

Applicants for the International Track must submit Educational Commission for Foreign Medical Graduates (ECFMG) certification and documentation of residency training in Otolaryngology, General Surgery, or Plastic Surgery as appropriate for the fellowship applied for with the expectation of completion of that training by the expected fellowship start date of the corresponding match cycle in order to participate in the match.

For more information on international applicant eligibility, please visit:

https://www.ahns.info/residentfellow/fellowships/international

ECFMG Number

Where did you receive your medical education?*

Pre-Medical Education*

Please use the plus button to add more colleges/universities.

College/University Name

Degree Received

Date of Graduation

City, State

Post Graduate Education*

Please use the plus button to add more colleges/universities.

College/University Name

Degree Received

Date of Graduation

City, State

Please upload your CV*

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 64 MB.

Residencies/Fellowships

On 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?*

Residency/Fellowship 1

Institution*

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Program Director*

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Institution Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

Why were you not able to complete the program?*

Residency/Fellowship 2

Institution*

Program Director*

Institution Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

Why were you not able to complete the program?*

Residency/Fellowship 3

Institution*

Program Director*

Institution Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

Why were you not able to complete the program?*

Peer References

Peer References*

Please list your references below and upload any letters you have received. Letters of reference can also be submitted after the application form has been sent – send additional letters to https://www.ahns.info/atc-letter-of-recommendation-submission/

First and Last Name of Reference

1 of 3 Letters of Reference

Drop files here or