Medical Microbiology Fellowship Application Form

Medical Microbiology Fellowship

Application Form

Required Documents:

Completed Standardized Application for Pathology Fellowships with your signature
Updated Curriculum Vitae (CV)
Cover letter and/or personal statement
Photo
Three letters of recommendation to be submitted by letter writers

Niaz Banaei, MD

Professor of Pathology

Director, Medical Microbiology Fellowship Program

Email: nbanaei@stanford.edu

Rachael Alegre Buenafe-Jacinto

Fellowship Program Coordinator

Email: rjacinto@stanford.edu

First Name:*

Last Name:*

Email:*

Phone number:*

Phone

Have you used another name:*

Select or enter value

Please list other names used:*

Date of Birth:*

(mm/dd/yyyy)

Present Address:*

(Street, City, State, Zip Code)

Gender:*

Select or enter value

Self Identification:*

Please select all that apply

Select or enter value

Training period for which applying:*

Select or enter value

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.”

Board Certification:*

Do you currently have any board certifications?

Select or enter value

Board:*

Please list the boards in which you hold certifications

Area of Board Certification:*

Date of certification:*

Undergraduate School:*

Please list the College/University you attended

Undergraduate Degree:*

Undergraduate Major:*

Undergraduate Dates:*

(Mo/Yr) to (Mo/YR)

Other Experience:

In chronological order, list other educational experiences, jobs, military service, or training that is not accounted for above

Name of Medical School:*

Location of your Medical school:*

(City, State)

Medical School Start and End Date(s):*

(Mo/Yr) to (Mo/Yr)

Name of Residency Program:*

Location of Residency Program:*

(City, State)

Please list residency track if applicable:

Residency Start and End date(s):*

(Mo/Yr) to (Mo/Yr)

Have you completed any other GME Fellowships:*

Select or enter value

Name of Fellowship:*

Location of other Fellowship:*

(City, State)

Fellowship Start and End Dates:*

(Mo/Yr) to (Mo/Yr)

At the time of your start with Stanford:*

Will you be a US Citizen?

Select or enter value

If no, what is your country of citizenship: *

At your start date with Stanford:*

Will you require a J1 Visa?

Select or enter value

First Reference:*

Please provide the individuals who will write your letters of recommendation: First, Last Name, Title

First reference email:*

First reference Institution:*

First reference address:*

(Address, City, State, ZIP)

First reference telephone number:*

Phone

Second Reference:*

(First, Last Name, Title)

Second Reference Institution:*

Second Reference Address:*

(Address, City, State, ZIP)

Second Reference Email:*

Second Reference Telephone:*

Phone

Third Reference:*

(First, Last Name, Title)

Third Reference Institution:*

Third Reference Address:*

(Address, City, State, ZIP)

Third Reference Email:*

Third Reference Phone Number:*

Phone

Comment Box:

Use comment box for any additional information:

File Upload*

Please upload:

Completed Standardized Application for Pathology Fellowships with your signature
Updated Curriculum Vitae (CV)
Cover letter and/or personal statement
Photo

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse