Application for OGME 2 & Above

Grandview limits visiting student rotations to strictly electives for fourth year students to preview residencies.

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Residencies   Select ... Anesthesiology Diagnostic Radiology Emergency Medicine Family Medicine General Surgery Internal Medicine Neurology Neurosurgery OB/GYN Opthamology Orthopedic Surgery Otolaryngology Proctology Psychiatry                 Fellowships   Select ... Cardiology Interventional Cardiology Hand Surgery Hematology/Oncology Nephrology Vascular Surgery

Personal Information * Name: * AOA#: Date of Birth:     * Email:  Current Address:   City:     State:  AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY    Zip:  Phone:       NPI#:    Visa Sponsorship Needed?   Yes     No Certifications   BLS Exp Date:     ACLS Exp Date:     PALS Exp Date:     ATLS Exp Date:   Licensure License #:      State   AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY    Exp Date:   License #:      State   AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY    Exp Date:   License #:      State   AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY    Exp Date:   Have you ever had your medical licensure suspended / revoked/ voluntarily terminated?   Yes     No        If yes, please explain: Are you currently board certified?   Yes     No        If yes, please list your certification and expiration: Have you ever engaged in private practice?   Yes     No        If yes, please list: Have you ever been named in a malpractice suit?   Yes     No        If yes, please explain: Have you ever been convicted of a felony?   Yes     No        If yes, please explain: Have you ever been convicted of a misdemeanor?   Yes     No        If yes, please explain: Medical School Institution: Address: City, State, Zip: Phone #: From:     To:   Dean: Major & Degree: Minor: Publications Awards / Memberships Was your medical school training interrupted?   Yes     No        If yes, please explain: Did you successfully complete training?   Yes     No OGME-1 Training Institution: Address: City, State, Zip: From:     To:   DME: Program Director Name: Phone #: Medical Education Contact Person: Medical Education Contact: Phone Number:     Email:   Specialty: Publications Was your training interrupted?   Yes     No        If yes, please explain: Did you successfully complete training?   Yes     No Residency Training Institution: Address: City, State, Zip: From:     To:   DME: Program Director Name: Phone #: Medical Education Contact Person: Medical Education Contact: Phone Number:     Email:   Specialty: Publications Was your training interrupted?   Yes     No        If yes, please explain: Did you successfully complete training?   Yes     No How to Complete Your Application Complete files require: Transcripts Dean's letter of recommendation Three (3) professional letters of recommendation DME letter (Residents) Curriculum Vitae Personal statement Copy of board scores Copy of medical school diploma Copy of OGME-1 Certificate / Letter Copy of Residency Certificate - if applicable

By checking this box I certify that everything within this application is accurate and complete.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other legally protected status.

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