Intern/Resident Application

Intern/Resident Applications can be submited using the electronic form below or by completing and mailing the printable form to:

UHHS Richmond Heights Hospital
Department of Medical Education
27100 Chardon Road
Richmond Heights, Ohio 44143
FAX: (440) 585-6141

Intern/Resident Application

Traditional Rotating Internship		Internal Medicine Fast Track Internship
Family Practice Emphasis Internship		Pediatrics Fast Track Internship
Dermatology Residency		Pediatrics Residency
Family Medicine Residency		Sports Medicine Residency
Internal Medicine Residency		Cardiology Fellowship

Training Year Applying For

Applicant Information

First Name	M.I.	Last Name

Current Address		Phone Number

		Email Address

Permanent Address (if different from above)		Phone Number

		Contact Person

Social Security Number		AOA Number

Educational Experience
In addition to application, please send CV.

Medical School(s) Attended
	From To
	Degree
	From To
	Degree
Colleges/Universities Attended
	From To
	Degree
	From To
	Degree

National Board Scores (please have originals sent)

	Date	Score	Pass/Fail
Part I			Pass Fail
Part II			Pass Fail
Part III			Pass Fail
Certifying Exam			Pass Fail

Honors: Please list honors you have received while in professional school, e.g., scholarships, honor societies, graduation honors, etc.

Publications: Please list original papers authored while in professional school (published or accepted for publication). Subject to verification.

Research Projects: Please list research projects in which you have participated while in professional school. Subject to verification.

Extracurricular Activities: Please list any extracurricular activities in which you participated while in professional school. Provide activity dates, e.g., volunteer projects, etc.

Additional Comments: Use this space to complete any question that requires additional space to fully discuss or explain your response.

Have you ever been convicted of a felony?	Yes No	If yes, please explain in Additional Comments Section above.
Have you ever served in a postgraduate internship or residency program previously?	Yes No	If yes, please provide additional information in the Additional Comments Section above.
Have you ever had any suspensions of prvileges in your program?	Yes No	If yes, please explain in the Additional Comments Section above.
Do you currently hold a Medical License?	Yes No	State License Number
Has your license ever been revoked?	Yes No N/A	If yes, please explain in the Additional Comments Section above.
Have you ever had any interruption in your training (undergraduate through residency)?	Yes No	If yes, please explain in the Additional Comments Section above.
Do you currently hold a valid DEA certificate?	Yes No	Certificate Number

Service Obligations (National Health Service Corps, Armed Forces Scholarships, State Programs, etc.)

	I am not required to fulfill any service obligations.
	I am committed to fulfill a service obligation beginning (month/year). Number of years committed:

CERTIFICATION OF STATEMENT:
I have read and understand the instructions and other information on this application. I certify that the information recorded herein is complete and accurate to the best of my knowledge. I recognize that any intentional misrepresentation on my part may cause me to be disqualified from continuation in the application process and/or to be denied appointment to or dismissal from the medical education program.

I hereby authorize UHHS Richmond Heights Hospital, its staff and their representatives, to consult with my peers and others who may have information bearing on my current professional competence, character, health status, ethical qualification and ability to work cooperatively with others and consent to the release of such information to and by them.

I further consent to the inspection, by UHHS Richmond Heights Hospital, its staff and their representatives, of all documents that may be material to an evaluation of my qualifications and current competencies and consent to the release of such information to them.

By checking here, I am signing this form.

Date Signed

Applications are accepted throughout the year and trainees are selected on the basis of academic and personal qualifications regardless of race, sex, color, religion, national origin or marital status.

Personal Statement