Hematopathology Fellowship Application

Please note, if you are an international graduate, you must have completed your residency in a U.S. or Canadian ACGME-accredited program before you start the fellowship. If you have any questions or technical difficulties, please contact the program coordinator, Linda Ly at Linda.ly3@ucsf.edu.

Applicant Information

First Name*

Last Name*

Primary Email Address*

NRMP Match ID*

Academic Year*

Please state which academic year you are applying for. For example, "2025-2026".

Date of Birth*

Gender*

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

Male

Female

Other

Prefer Not to disclose

Ethnicity/Race*

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

Select or enter value

Citizenship*

U.S. Citizen or U.S. Non-citizen National

Permanent Resident of U.S.

Other

Please indicate the country of your citizenship

Visa Status*

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

U.S. Citizen - No Visa

Permanent Resident of U.S.

J-1 ECFMG Sponsored Visa - Transfer from current institution

Will need to apply for a J-1 ECFMG Sponsored Visa

H-1B Visa

Other (please indicate)

Other Visa Status

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

If applicable

City and State

Internship Start Date

Internship End Date

Residency*

Please list hospital or insitution

PGY Level(s)/Type of Residency*

Enter your current PGY level, along with the specialty you were in (ie. Anatomic Pathology, Clinical Pathology, Anatomic and Clinical Pathology). For example, "PGY-5, Clinical Pathology".

Residency's City and State*

Residency Start Date*

Residency End Date*

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 & Certifications

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 GRADUATES ONLY

Do you possess an ECFMG Certificate?

Yes

Board Status

If applicable

Select or enter value

If certified,

Please enter your certificate number here.

States where you are licensed to practice

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

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 to any of the above, please explain:*

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: You may email the letters to the program coordinator directly. We require a minimum of 3 letters of recommendations, and we prefer at least one from a hematopathologist. You may have up to a maximum of 4 letters of recommendation.

Program Director's Name and Email

Reference #1 Name and Email

Reference #2 Name and Email

Reference #3 Name and Email

Reference #4 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.

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

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