Neurosurgical Oncology Clinical Instructorship

Neurosurgical Oncology Clinical Instructorship

First Name*

Last Name*

Email*

Citizenship*

Current position

Position title*

Hospital*

Visa status*

Medical school

Please list below the name of the medical school/s attended, exactly as it appears on the diploma. Please attach a photocopy of your medical school diploma to the present application. Please check if the name of the medical school diploma exactly matches with the name of the medical school listed on the website of the Medical Board of California (available here).

If the name does not match, please contact the Medical Board's Licensing Program at (916) 263-2382, to verify that your medical school is recognized by the Medical Board of California. In that case, please send us a written confirmation by the Medical Board of California.

Medical School*

Year of Graduation*

Medical school name verification*

Please check the box below to verify that the name of your medical school is recognized by the Medical Board of California

Residency Program*

Please list the name of your residency program exactly as it appears on your diploma.

Experience in the USA and Canada

Please list below, in chronological order, all the research and clinical experiences (internship, fellowship, observership) in the U.S.A. and Canada, only.

If there is additional experience that does not fit on this form, please attach a word document attachment with details in the "File Upload" section.

Experience 1 Title

Experience 1 Hospital

Experience 1 Program Director

Experience 1 Start Date

Experience 1 End Date

Type of Visa for Experience 1

J-1

H-1b

0-1

B-1

Experience 1 accreditation

If this is a clinical fellowship, is it accredited by ACGME or RCPSC ?

Yes

Add experience 2?

Experience 2 Title

Experience 2 Hospital

Experience 2 Program Director

Experience 2 Start Date

Experience 2 End Date

Type of Visa for Experience 2

(if not US citizen or permanent resident)

J-1

H-1b

0-1

B-1

Experience 2 accreditation

If this is a clinical fellowship, is it accredited by ACGME or RCPSC ?

Yes

Add experience 3?

Experience 3 Title

Experience 3 Hospital

Experience 3 Program Director

Experience 3 Start Date

Experience 3 End Date

Type of Visa for Experience 3

(if not US citizen or permanent resident)

J-1

H-1b

0-1

B-1

Experience 3 Accreditation

If this is a clinical fellowship, is it accredited by ACGME or RCPSC ?

Yes

Add Experience 4?

Experience 4 Title

Experience 4 Hospital

Experience 4 Program Director

Experience 4 Start Date

Experience 4 End Date

Type of Visa for Experience 4

(if not US citizen or permanent resident)

Select or enter value

Experience 4 Accreditation?

If this is a clinical fellowship, is it accredited by ACGME or RCPSC ?

Select or enter value

Select start date*

Instructorship begins July 1st of every year. Candidates are invited to select one or more start dates, whenever possible:

7/2023

7/2024

7/2025

7/2026

File Upload*

All of the below documents are required for submission:

CV
Letter of recommendation 1
Letter of Recommendation 2
Letter of Recommendation 3
Personal Statement
Neurosurgery Residency Diploma
USMLE Step 3 score report

Drag and drop files here or

Form Date Field

Send me a copy of my responses

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