Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 87 views

    Oklahoma State Medical Association Observership Program Application

    Uploaded by

    redhotdevil1987
    This document is an application for an observership program with the Oklahoma State Medical Association. It requests biographical information from the applicant such as name, date of birth, contact information, education history, medical licensing exam scores, postgraduate experience, and answers to questions about their professional history and conduct. The completed application and supporting documents must be mailed together to the specified address for consideration in the observership program.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Oklahoma State Medical Association Observership Program Application

    Uploaded by

    redhotdevil1987
    87 views3 pages
    This document is an application for an observership program with the Oklahoma State Medical Association. It requests biographical information from the applicant such as name, date of birth, contact information, education history, medical licensing exam scores, postgraduate experience, and answers to questions about their professional history and conduct. The completed application and supporting documents must be mailed together to the specified address for consideration in the observership program.

    Original Description:

    Oklahoma Medical Observership

    Original Title

    Application 1010

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is an application for an observership program with the Oklahoma State Medical Association. It requests biographical information from the applicant such as name, date of birth, contact information, education history, medical licensing exam scores, postgraduate experience, and answers to questions about their professional history and conduct. The completed application and supporting documents must be mailed together to the specified address for consideration in the observership program.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    87 views3 pages

    Oklahoma State Medical Association Observership Program Application

    Uploaded by

    redhotdevil1987
    This document is an application for an observership program with the Oklahoma State Medical Association. It requests biographical information from the applicant such as name, date of birth, contact information, education history, medical licensing exam scores, postgraduate experience, and answers to questions about their professional history and conduct. The completed application and supporting documents must be mailed together to the specified address for consideration in the observership program.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 3

    Oklahoma State Medical Association

    Observership Program
    Application
    Applicant Information

    Full Name:

    Last

    Other names you have


    used:

    Date:

    Middle name

    Name you would like to be called:


    Date of birth:

    First

    Nationality:

    Gender:

    MMDDYYYY

    M or F

    Date of availability to start the observership :

    Visa Status:

    MMDDYYYY

    Will you have a car during your rotations?


    Current Mailing address in the
    USA:

    Street Address

    Apartment/Unit #

    City

    Phone:

    ()

    E-mail Address:

    State

    ZIP Code

    NOTE: Email will be the method of communication between the OSMA and the Applicant

    Permanent Mailing Address:

    References- Include the names and addresses of 2 physicians that can provide a personal reference
    Current Mailing address in
    the USA:

    Name

    Address

    State

    ZIP Code

    City

    Current Mailing address in


    the USA:

    Name

    Address

    State

    ZIP Code

    City

    Education- List the name of each institution attended. Provide the address of the institution and the dates of attendance.
    Use a sheet of paper if needed.
    1.

    Name and address:

    Name

    Address

    2.

    Name and address:

    Name and address:

    Name and address:

    Dates attended

    Name

    Address

    Degree/certificate

    Dates attended

    Name

    Address

    4.

    Degree/certificate

    3.

    Degree/certificate

    Dates attended

    Name

    Address

    Degree/certificate

    USMLE Scores
    1.

    Step I:

    Date

    Score

    2.

    Step II:

    Date

    Score

    3.

    Step II CSA:

    Date

    Score

    Page 1

    Dates attended

    Oklahoma State Medical Association


    Observership Program
    Application
    4.

    Step III:

    Date

    Score

    Postgraduate Experience: List the name and address of each program and/or experience attended regardless of whether the
    program was completed or credit was received
    1.

    Name and address:

    Name

    Address

    2.

    Name and address:

    City

    Street Address

    Degree/certificate

    Dates attended

    Apartment/Unit #

    City

    Name and address:

    4.

    Dates attended

    Apartment/Unit #

    Name and address:

    Degree/certificate

    Street Address

    3.

    Degree/certificate

    Dates attended

    Street Address

    Apartment/Unit #

    City

    Degree/certificate

    Dates attended

    Questions
    YES

    NO

    YES

    NO

    YES

    NO

    Have you ever been charged with, or been found to have committed, unprofessional conduct, professional
    incompetence, gross negligence, or repeated negligent acts by any medical board, other agency or hospital?

    YES

    NO

    Have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired
    practitioner program?

    YES

    NO

    Have you been treated for or had a recurrence of a diagnosed addictive disorder?

    YES

    NO

    Do you have any other condition which in any way impairs or limits your ability to practice medicine safely?

    YES

    NO

    Is any criminal action pending against you?


    Are you required to register as a Sex Offender?
    Have you ever been denied a license to practice medicine?

    If yes, explain:

    Complete application packet

    Completed application form


    Resume or Curriculum Vitae
    Evidence of completion of medical education
    USMLE Score Reports
    ECFMG certificate if available
    Copy of visa
    Copy of passport- information page, picture page, signature page, inside back cover page
    1 passport photo
    $250 cashiers check or money order for the non-refundable application fee made out to the Oklahoma State Medical
    Association.

    Be certain to read the entire observership overview.


    *Any document that is written in a language other than English must be accompanied by an original, official translation.
    Please mail the completed packet to the following address. Documents that are emailed or faxed will not be accepted.
    Oklahoma State Medical Association
    IMG Observership

    Page 2

    Oklahoma State Medical Association


    Observership Program
    Application
    313 NE 50th
    Oklahoma City, OK 73105

    Disclaimer and Signature


    I certify that my answers are true and complete to the best of my knowledge. I have read the observer overview and submit my application for the
    Observership program.
    Signature:

    Date:

    Page 3

    You might also like