Application for Observership
Department of Internal Medicine
Long Island College Hospital
Date: ______________
Name of Applicant: _________________________________
Local Address: ____________________________________
____________________________________
Local / Cellphone Number: _______________________________
Division Requested: _________________________________
Start Date Requested: _________________
Goals and Objectives of this Activity:
Medical School: ___________________________ Location: _____________________
Dates of Attendance: From: ___________ To: ___________ Degree: _______
ECFMG Certificate Number: _______________________________________
(Attach copy ECFMG Certificate to this form)
Citizenship Status: (check one of the following)
□ U.S. Citizen □ Permanent Resident
□ Non-Resident Alien: (indicate type of visa currently held)
□ B-1 □ B-2 □ F-1 □ F-2 □ H-1 □ H-4 □ J-1 □ J-2B □ other __________
Passport Country: __________________________
Visa Expiration Date: _______________________
By signing this application I agree that all of the information provided by me is complete and accurate. I agree to the terms of this observership as outlined in the Guidelines for Observership in the Department of Internal Medicine at Long Island College Hospital Signature of Observer: __________________________________ Printed Name: __________________________________ |
Please return this form with:
□ copy of curriculum vitae
□ Copy of medical school diploma and final transcript
□ Copy of visa (if applicable)
□ Copy of ECFMG certificate
□ Two letters of recommendation from physician supervisors, instructors or mentors
□ Tuition payment $500.00 per 4 week rotation. Make check payable to The Department of Internal Medicine-LICH
For Department of Medicine Use Only |
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Signature of Residency Program Director: ____________________________ Signature of Supervising Attending: _________________________________ |