ACADEMIC GENERAL PEDIATRICS FELLOWSHIP PROGRAMS COMMON APPLICATION For the 2021 Fall Pediatric Subspecialty NRMP Match Fellows start date of July 1, 2022 All fellowship applicants interested in applying for the programs listed below must register for the Pediatric Fall Specialties NRMP Match at https://r3.nrmp.org/viewLoginPage                    Academic General Pediatrics Fellowship at the Renaissance School of Medicine at Stony Brook University* Stony Brook, NY Baylor College of Medicine/Texas Children's Hospital Academic General Pediatrics Fellowship*, Houston Boston Children’s Hospital, General Academic Pediatric Fellowship, * Boston Boston University Medical Center Primary Care Academic Fellowship, Boston Children’s Hospital at Montefiore Academic General Pediatrics Fellowship, Bronx, NY Children’s Mercy Kansas City, Academic General Pediatrics Fellowship, Kansas City, MO* Cincinnati Children’s Hospital, General Pediatric Research Fellowship *, Cincinnati Cohen Children's Medical Center at Hofstra/Northwell Academic General Pediatrics Fellowship, New Hyde Park, NY General Academic Pediatrics Fellowship in Health Equity at Children’s Hospital Los Angeles, Los Angeles, CA Johns Hopkins School of Medicine*, Baltimore, MD Nationwide Children's Hospital, The Ohio State University College of Medicine , Columbus, OH Nemours/Alfred I. duPont Hospital for Children Academic General Pediatrics Fellowship *, Wilmington, Delaware Stanford University, Palo Alto, California The Medical University of South Carolina, Charleston, SC UC Davis Children’s Hospital *, Sacramento, CA University of Minnesota*, Minneapolis & Saint Paul University of Oklahoma Health Sciences Center, Oklahoma City, OK University of Rochester Medical Center*, Rochester, NY Vanderbilt University Medical Center, Nashville *Academic Pediatric Association Accredited Fellowship Training Programs Profile First Name: Middle Name: Last Name: Suffix: Previous Last Name: Contact Email: Date of Birth: Phone: Emergency Contact (Name and Number): Mailing Address Street Address: City: State/Province: Zip/Postal Code: Citizenship ☐ US Citizen ☐ US Permanent Resident ☐ Other (Please list): If you are a foreign national outside the US, or currently in the US on a valid visa status, please note the programs that accept Visa applicants and respond to the questions below. IF NOT A FOREIGN NATIONAL, SKIP TO THE SECTION LABELED “EDUCATION SECTION: General educational information” below the ECFMG/TOEFL scores. Programs that accept Visa applicants:      Children’s Hospital at Montefiore Academic General Pediatrics Fellowship, Bronx, NY Nemours/Alfred I. duPont Hospital for Children Academic General Pediatrics Fellowship * Wilmington, Delaware Children’s Mercy Kansas City, Academic General Pediatrics Fellowship, Kansas City, MO Stanford University, Palo Alto, California University of Oklahoma Health Sciences Center, Oklahoma City, OK Will you need a “visa sponsorship” through the teaching hospital (J1, H1B, etc.) to participate in US fellowship training? ☐ Yes ☐ No If yes to above:    Please specify type of Visa: Did you train at a foreign medical school? ☐ Yes ☐ No Is your medical school listed on the approved list for state licenses to which you will be applying? ☐ Yes ☐ No ☐ Unsure* *If you are unsure, please contact the programs to which you are applying. Obtaining state license, for the state in which you will be training, is mandatory to being fellowship. ECFMG/TOEFL Scores Please provide documentation for your ECFMG and/or TOEFL scores in the space below. EDUCATION SECTION: General Education Information College/University: From: To: City, State: Medical School: City, State: Internship: City, State: Residency: City, State: Other Training: City, State: Degree : From: To: Degree : From: To: Degree : From: To: Degree : From: To: Degree : 1. Was your medical education/training extended or interrupted? ☐ Yes ☐ No If yes, please note the date and comment: Licensure Information This section allows entries for each of your state medical licenses. Have you passed the USMLE Step 3? ☐ Yes ☐ No ☐ No current medical license (If you do not have a current medical license, skip to the “Board Certification” questions.) Entry 1 State: License Number: License Type: Expiration Month/Year: Entry 2 State: License Number: License Type: Expiration Month/Year: DEA Number (DEA is for US Medical License holders only.) DEA Registration Expiration