EDUCATION > Residents/Residency


2015 Endourology Fellowship Match

To register for the 2015 Endourology Fellowship Match, please fill out the form below.

Fields in Red are required:

Email:

First Name:

Middle Initial:

Last Name:

Name Suffix:

(Jr., III, etc.)

Credential:

(MD or Ph.D.)

 

Current Address:

Address:

City:

State:

Zip:

Country:

Is the above your Home or Office Address?

Office    Home

Telephone:

 

Permanent Address:

Address:

City:

State:

Zip:

Country:

Is the above your Home or Office Address?

Office    Home

Telephone:

 


Provide telephone numbers (not necessarily your own) through which we can reliably reach you during the matching period (July, 2014).

Country

Area Code

Phone Number

Extension

Daytime:

 Relationship:

Nighttime:

 Next of Kin:

Pager Number:

 

Gender:

Male         Female

Birth Date:

Place of Birth:

Citizenship:

Visa (if applicable):

Social Security Number:

Marital Status (optional):

Spouse Name (optional):

 

Education and Training:

College/University:

City/State:

Degree/Date:

Postgraduate Schools:

Degree/Date:

Medical School:

City/State:

Degree/Date:

Urology Residency:

City/State:

Completion Date:

Postgraduate work includes previous residencies, assistant residencies, fellowships and internships with dates and names of hospitals and schools. List all postgraduate medical courses taken and all internships, residencies or fellowships on additional pages if there is not enough space below. If you have ever left any course or residency, internship or fellowship for any reason other than the expiration of the usual term, please state the reason.

National and State Medical Board Examination
USMLE Exams
(Date /Result/Scores/Percentile):

States in which licensed:

 

Honors and Awards:

High School:

College/University:

Medical School:

 

Research:

Research Experience (dates):

Research in Progress:

Published Abstracts and Papers:
(May refer to CV if listed there)

Urology Rotations (date/location):

1)

2)

 

Personal Health:

Present State of Health:

Last Chest X-Ray (date/result):

Last TB Skin Test Ray (date/result):

Medical Condition that may affect fellowship performance:

 

Letters of Recommendation:

Name, Address, Telephone Numbers of the 3 individuals from whom letters were requested; these should be from Urologists with whom you have worked. If you performed substantial research, please consider having the faculty with whom you worked send us an additional letter of recommendation.

1)

2)

3)

 

OPTIONAL: Identify your racial /ethnic background:

No Answer
Black
American Indian or Alaskan Native
White
Hispanic - Mexican/American or Chicano
Hispanic - Puerto Rican (Mainland)
Hispanic - Puerto Rican (Commonwealth)
Asian - Pacific Islander

 

Please submit a personal statement of "why you are seeking an Endourology Fellowship and your urologic professional plans following the fellowship. Finally where you hope to be a decade after your Fellowship"

Please limit personal statement to less than 4,000 characters.

 

Note:
The Endourological Society is committed to increasing the representation of women and members of minority groups in its fellowship training programs, and particularly encourages applications from such individuals.


There is a $200 non-refundable charge to register for the Match Program.Please complete the following credit card information:

Please check this box if you have already provided payment to Endourological Society

Credit Card:

American Express
Mastercard
Visa

Card Number:

Expiration Date:

Month   / Year 

Name on Card:

Please type your full name. This will act as your electronic signature:

 

You will receive an email confirmation after submitting your information.

Inquiries pertaining to the Match please contact the address below.

AUA Residency Match Program
1000 Corporate Blvd
Linthicum, MD 21090
Fax: 410-689-3939
Phone: 410-689-3913
Email: endomatch@auanet.org



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