Swedish Neurosurgery Fellowships Application

1.	First name*

2.	Last name*

3.	Sex

4.	Birthdate*

5.	Preferred Pronoun

6.	Address (Mailing)*

7.	Address line 2

8.	City*

9.	State*

10.	ZIP code/Postal code*

11.	Address (Permanent, if different than above)

12.	Address line 2

13.	City

14.	State

15.	Zip code/Postal code

16.	Home phone number

17.	Cell phone number*

18.	Email address*

19.

What Fellowship Program are you interested in?*

	Cerebrovascular/Endovascular
	Complex and Minimally Invasive Spine
	Interventional Spine
	Skull-Base

20.

Term*

	1 year
	2 year

21.

Undergraduate

Institution
Degree
Dates of Attendance

22.

Medical School*

Institution
Degree
Dates of Attendance

23.

If you are an international medical graduate, Are you E.C.F.M.G certified?*

No

If yes, Please specify Certificate Number and Issue Date

24.

Residency*

Institution
Specialty
Dates of Attendance

25.

Post Graduate Experience/Fellowships

Institution
Specialty
Dates of Attendance

26.	Have you taken and passed USMLE Step(s) 1, 2 Clinical Knowledge (CK), and 3?* USMLE Steps 1-3 is a requirement for all applicants
	Yes No

27.	Are you authorized to work in the U.S.?*
	Yes No

28.	What is your current work authorization? (US Citizen, Permanent Resident, etc.)

29.	Are you seeking work authorization and sponsorship?* Swedish Neuroscience Institute sponsors H-1B Visas only. You will not be considered eligible for fellowship within our program(s) if you will require a J-1 Visa, J-1 Conrad waiver or an O-1 at time of Fellowship.
	Yes No

30.	Please list current and expired State Medical Licenses (License Number, State, Duration)

31.	Do you have an active unrestricted DEA License (Federal or Institution)?*
	Yes No

32.	Do you have an NPI?*
	Yes No

33.	Are you Board Certified or Board Eligible in the United States or Canada?*
	True False

34.

Has your medical license ever been suspended/revoked/voluntarily terminated?*

No

If yes, please specify:

35.

Have you ever been named in a malpractice case?*

No

If yes, please specify:

36.

Have you ever been convicted of a misdemeanor in the United States?*

NO

If yes, please specify:

37.

Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?*
This section is not intended to solicit information about your health, disability, or family status

No

If yes, please specify:

38.

Have you ever been convicted of a felony in the United States?*

No

If yes, please specify:

39.	Are you able to carry out the responsibilities of a fellow in our program, including the functional requirements, cognitive requirements, and interpersonal and communication requirements with or without reasonable accommodations?*
	Yes No

40.

I understand that in order for my application to be processed, I need to send my Curriculum Vitae (CV), Personal Statement, minimum of two letters of recommendation, Relevant Exam reports (IE United States Medical Licensing Examination Scores) and a recent headshot via email.*

I understand

Disclaimer:

I understand that by completing this fellowship application I am expressing my interest in a fellowship opportunity with the Swedish Neuroscience Institute (SNI). The completion of this application does not constitute an application for employment with SNI or Swedish Medical Center, nor does it guarantee acceptance to SNI fellowship training. Should I be favorably considered for an SNI fellowship, I understand I will be required to complete a separate employment application.

41.

I have read the disclaimer and understand this is not an application for employment.*

I understand