Herbert Perkins Cellular Therapy and Transfusion Medicine Fellowship Application

If you have any questions or concerns, please contact the program coordinator, Linda Ly, at linda.ly3@ucsf.edu.

Residency in a U.S. or Canadian ACGME program*

Will you have completed a residency* in a U.S. or Canadian ACGME-accredited program before you start the fellowship? *Residencies such as Anatomic Pathology, Clinical Pathology, AP/CP, Internal Medicine, Hematology/Oncology, Pediatrics, and/or Anesthesiology.

Yes

We regret to inform you that you currently do not meet the eligibility requirements at this time. When you have met the eligibility requirements, we encourage you to apply again in the future. Thank you!

Applicant Information

Primary Email Address*

Academic Year*

Please state which academic year you are applying for. For example "2024-2026".

Gender*

If you do not wish to disclose your gender, please state "Prefer not to disclose."

Ethnicity and Race*

If you do not wish to disclose your ethnicity and/or race, please select "Prefer not to disclose".

Select or enter value

Citizenship/Visa Status*

Your citizenship and/or visa status will not affect candidacy. This information is used for coordinating the transfer of your Visa from your previous institution, if needed.

Select or enter value

Visa Expiration

If you do not need a Visa, disregard this question.

Address*

U.S. or International Address

Primary Phone Number*

Ex: (999) 999-9999

Education and Training

Premedical College

If you are an international graduate, you may skip this question.

Premedical College Graduation Date

Premedical College Degree Conferred

Medical School*

If you are an international graduate, enter your medical school here.

Medical School Graduation Date*

Medical School Degree Conferred*

Internship City and State

Internship Start Date

Residency*

Hospital or Institution

PGY Level(s) / Type of Residency*

Enter your PGY level, along with the specialty you were in (ie. Anatomic Pathology, Clinical Pathology, Hematology/Oncology, etc.).

Other residencies and/or fellowships?

Please list any other residencies and/or fellowships you have completed or are planning on pursuing. List the residences/fellowships with the institution's name and the start/end dates of the training.

Gaps in education and training

Please explain any chronological gaps in education/training/employment since graduating from medical school. Or you may attach a pdf document with your explanation at the end of the application.

Exams and Certification

USMLE 1 or COMLEX 1 Exam Date

USMLE 1 or COMLEX 1 Score

USMLE 2 (CS) or COMLEX 2 (PE) Exam Date

USMLE 2 (CS) or COMLEX 2 (PE) - Pass/Fail

USMLE 2 (CK) or COMLEX 2 (CE) Exam Date

USMLE 2 (CK) or COMLEX 2 (CE) Score

USMLE 3 or COMLEX 3 Exam Date

USMLE 3 or COMLEX 3 Score

International Students Only - If you have a ECFMG Certificate, please enter your certificate number here:

ABMS Board Status

Board Certified

Board Eligible

I will have just completed residency

Other (please specify)

If board certified,

Please list which specialties and/or subspecialities you are certified in.

If other, please specify below

States where you are licensed to practice?

Please list state(s), license #, and expiration date

Other

You will be required to complete an attestation form if you are offered a fellowship at UCSF. Do you anticipate that any of your answers on the attestation form might impede successful completion of the hiring process? (Click the link below to view the attestation form) https://ucsf.box.com/s/vuxc1wm1b6m3yzcstshgnbsnqu0m98wa

Any issues that might hinder hiring process?*

Yes

Have you ever been denied or lost a state license?*

Yes

If yes, please explain why below:*

References

Please list your references' name and email below. Should we have any questions, we will contact them via the contact information listed below. For letters of recommendation: Please have your letter writers email their letters to the program coordinator directly. We require a minimum of 3 letters of recommendations, and preferably one from your program director if applicable. You may have up to a maximum of 4 letters of recommendation.

Reference #1's Name and Email

Reference #2's Name and Email

Reference #3's Name and Email

Reference #4's Name and Email

Supplemental Documents

Please upload the following documents here (in PDF format): Required: Curriculum Vitae (CV) Personal Statement Optional: Photograph (preferably passport size) Miscellaneous information or documents.

File Upload*

Drag and drop files here or

ATTENTION - Review all attachments and information before submitting.

Make sure all the information you are submitting and attachments are up to date and correct. You will NOT be able to make any changes after you click submit. If you anticipate any changes or updates to your CV (i.e. manuscript submissions, meetings, awards, etc), you may bring any updates as supplemental information should you be offered an interview.

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