College of American Pathologists Residents Forum

Standardized Application for Pathology Fellowships

Applicant Name
Last name First Middle

Fellowship Type
This application is being made for a fellowship in (please check one):
Blood banking/Transfusion medicine Breast pathology

Chemistry Cytopathology

Dermatopathology Diagnostic immunology Please affix a recent passport-

sized photo here.
Forensic pathology Gastrointestinal pathology

Genitourinary pathology Gynecologic pathology If submitting electronically,

Hematopathology Medical microbiology include a recent passport-style
photo in .JPG format with the
Molecular genetic pathology Neuropathology application.

Pathology informatics Pediatric pathology

Pulmonary/Mediastinal pathology Renal pathology

Soft tissue/Bone pathology Surgical/Oncologic pathology

Other, please specify:

Start date Finish date

Training period for which applying:

Personal Data

Other names used:

Present Address
Street City State ZIP / Postal code

Permanent Address
Street City State ZIP / Postal code

Telephone
Home Work Mobile Fax

E-mail:

Citizenship
Country of citizenship Visa status
Education
(Mo/Yr) (Mo/Yr) (Undergraduate School) (Major) (Degree)

to
(Mo/Yr) (Mo/Yr) (Graduate School, if applicable) (Major) (Degree)

to
(Mo/Yr) (Mo/Yr) (Medical School) (Country) (Degree)

to
(Mo/Yr) (Mo/Yr) (Residency) (AP, CP, AP/CP, other)

to
(Mo/Yr) (Mo/Yr) (Other GME, if applicable) Area of training

to
(Mo/Yr) (Mo/Yr) (Other GME, if applicable) Area of training

to

Other Experience
In chronological order, list other educational experiences, jobs, military service or training that is not accounted for above.
(Mo/Yr) (Mo/Yr)

to
(Mo/Yr) (Mo/Yr)

to
(Mo/Yr) (Mo/Yr)

to

National Boards
Please indicate national board examination dates and results received.
USMLE Step 1 USMLE Step 2 USMLE Step 3
Date passed Score (optional) CK - Date passed Score (optional) CS - Date passed Score (optional) Date passed Score (optional)

For graduates of international medical schools, are you ECFMG-certified? Yes No If yes, provide certificate number and date granted.
ECFMG Certificate Number Date ECFMG Certificate Granted

(MM-YYYY)
COMLEX Level 1 COMLEX Level 2 COMLEX Level 3
Date passed Score (optional) CE - Date passed Score (optional) PE - Date passed Score (optional) Date passed Score (optional)

Medical Licensure
Please list any states in which you hold a license to practice medicine. Please provide a license number. If an application is
pending in a state, please write “pending.”
(State) (Date Issued) (Medical License Number) (Active?)

Yes No
(State #2) (Date Issued) (Medical License Number) (Active?)

Yes No
Have you ever been reprimanded, or had your license suspended or Yes (If so, please explain in an attached sheet.)
revoked in any of these states? No

Have you ever been named in (and/or had a judgment against you) Yes (If so, please explain in an attached sheet.)
in a medical malpractice legal suit? No
Board Certification
Please indicate any areas of board certification.
Board Area of Certification Date of Certification

Honors, Awards, Publications, Presentations, Memberships, Leadership/Research Experience

Please list on attached application forms or include this information in your CV.

Letters of Recommendation and/or References

Please list the individuals who will write your letters of recommendation. At least three are required.
Reference #1
Name Title

Institution

Address City State ZIP / Postal Code

Telephone Email

Reference #2
Name Title

Institution

Address City State ZIP / Postal Code

Telephone Email

Reference #3
Name Title

Institution

Address City State ZIP / Postal Code

Telephone Email

Reference #4 (optional)
Name Title

Institution

Address City State ZIP / Postal Code

Telephone Email

Signature (may omit if submitting electronically)

I hereby certify that all of the information on this application is accurate, complete, and current to the best of my knowledge, and that this
application is being made for serious consideration of training in the Pathology Fellowship indicated. I understand that accepting more than
one fellowship position constitutes a violation of professional ethics and may result in the forfeiture of all positions.
Signature Date
Honors and Awards (if explicitly listed on CV, include highlights here with reference to location on CV)
Publications and Presentations (if explicitly listed on CV, include highlights here with reference to location on CV)
 Memberships and Leadership/Research Experience (if explicitly listed on CV, include highlights here with reference to
location on CV)
Application Packet Check-list
 Completed Standardized Fellowship Application Form with Signature
 Updated Curriculum Vitae (CV)
 Included cover letter and/or personal statement
 Checked with the fellowship director or coordinator whether there are other items that should be included
 Included photo