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Application for Fellowship Training in Geriatric Medicine

Please complete and submit this application form online. When you have completed the form, click "Submit Application" at the bottom of this page. Before submitting, please print a copy for your own records.

Interviewing begins in August for the following academic year.

Questions?
Contact Academic Coordinator at (317) 630-2219 or Email:

Application for Fellowship Training in Geriatric Medicine
1.   First name:
2.   Last name (surname):
3.   E-mail address (required):
4.  
Addresses:    
  Current address Permanent address (if different)
Street
 
City
State (if U.S.)
ZIP or postal code
Country
5.  
Telephone numbers:
Preferred
contact		 Country prefix
(if any)		 Area code and number Extension
  Home
  Mobile
  Pager
6.  
Education (undergraduate and graduate):
School name City Dates Degree(s)
     
 
     
 
     
7.  
Medical training:
Hospital name City Dates Type
     
 
     
 
     
 
     
8.  
Board status:
  Board Number Date awarded
Eligible Certified
9.  
Medical licenses:
State License Number
10.  
Honors, academic societies, awards:
11.   Military service (dates, service rank, status):
   
12.  
Optional information:  
Marital status
Place of birth
Citizenship
Visa status
ECFMG no.
Race
Ethnicity
Name of spouse
Name and address of parent or relative who will know your address in the future
13.   When do you intend to start your fellowship training?  July
14.   What fellowship track would you like to pursue?
Academic Geriatrician:
     Clinician Educator (2 yrs)
     Clinician Researcher (3 yrs)
     Clinician Administrator (2 yrs)
Private Practice (1 yr)
Geriatric medicine + the following subspecialty:
Undecided
15.   Do you have any other comments or questions?
   

I hereby apply for clinical/research training as a Fellow in the Department of Medicine, Division of General Internal Medicine & Geriatrics, of the Indiana University School of Medicine.

In support of this application, I will submit the following additional items.

  • Curriculum Vitae
  • Diploma: a copy of my medical school diploma (translation if necessary)
  • United States Medical Licensing Exam transcript (copy OK if score is readable)
  • Four letters of recommendation for graduate medical education, as follows:
    • Program director
    • At least three other faculty members
  • Personal statement: a brief statement of special interests and career plans
  • ECFMG (Educational Commission for Foreign Medical Graduates) copy of certificate, if International Medical Graduate

Thank you for your input. Please remember to click "Submit Application" below.
Before submitting, please print a copy for your own records.

Geriatric Medicine Fellowship Program
Indiana University School of Medicine
Attn: Academic Coordinator
1001 W 10th Street, OPW-M200
Indianapolis, IN 46202-2879

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Last Updated On: January 25, 2012
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