A list of programs currently accepting applications appears at the bottom of this form. Please review this list to ensure that the program(s) you are interested in are accepting applications before completing the application form.

Please complete this application to be emailed to your chosen program(s). The program(s) will acknowledge receipt of your application, and you will be contacted for additional information if the program would like to initiate discussion.

Provide the following information. Please do not cut and paste your information from another software tool or editor such as Microsoft WORD or Wordperfect.

*  Denotes required fields


First Name*      Middle Initial      Last Name*  

Mailing address*   

Email address*    

Daytime Phone Number*    
  

Fax number   

Current Employer*  

Job Title*   

Place of Birth   

U.S. Citizen    yes    no      If no, list citizenship   

Academic Degrees*
         Degree     School     Date Conferred 
         Degree     School     Date Conferred 
         Degree     School     Date Conferred 

Please answer as applicable:

Name of PhD advisor: 

Name of Dean of the Medical School: 

Name of Intern/Residency Program Director: 

Residency location if applicable: 

Fellowship location: 

Medical Microbiology or Immunology Experience: 

Other Relevant Experience: 

Honors, professional awards, and memberships: 

List of publications and abstracts:

(1000 characters max.) 1000 remaining

Describe experience relevant to interpersonal and/or administrative skills, teaching, and medical microbiology or immunology.

(1000 characters max.) 1000 remaining

Describe your background, interests, and research in medical microbiology or immunology.*
(1000 characters max.) 1000 remaining

Describe your career goals and your reasons for applying.*

(1000 characters max.) 1000 remaining

Are you licensed to practice in any state(s). Please list.


International (excluding Canadian) applicants: 

Have you taken the Test of English as a Foreign Language (TOEFL) exam?   Yes  No

       If yes, list your total score and individual scores for listening, speaking, reading, and writing (where applicable).
      

Have you taken and passed the Foreign Medical Graduate Examination in Medical Sciences (FMGEMS)?  Yes  No

Are you certified by the Educational Commission for Foreign Medical Graduates (ECFMG)?  Yes  No

Have you completed a post-graduate training program in the United States?  Yes  No

      If yes, provide institution name, type of training program, and the dates of participation:
      

 

Please select which programs you wish to e-mail an application to:

 Beth Israel Deaconess Medical Center, James Kirby
 Mayo Clinic, Nancy L. Wengenack
** National Institutes of Health, Adrian Zelazny
 Rosalind Franklin University of Medicine and Science, Immunology, Kenneth Beaman
University of California, Los Angeles, Clinical Microbiology, Omai Garner
University of Nebraska Medical Center, Steven H. Hinrichs and Peter C. Iwen
**University of North Carolina Hospitals, Microbiology, Peter Gilligan
University of North Carolina Hospitals, Immunology, John Schmitz
** University of Pennsylvania, Paul Edelstein and Irving Nachamkin
** University of Rochester School of Medicine & Dentistry, Marilyn A. Menegus and Dwight J. Hardy
** University of Utah Medical Center, Immunology, Anne Tebo
 University of Utah Medical Center, Microbiology, Mark Fisher
** University of Washington, Jill Clarridge
 Vanderbilt University Medical Center, James Chappell
** Washington University, Carey-Ann Burnham

** These programs are not accepting applications at this time. Please review the programs’ descriptions for more information.

You will receive an email confirming your application submission shortly. If you receive an e-mail from the system administrator notifying you that the e-mail was undeliverable, please contact certification@asmusa.org for assistance.

             

 

Last Modified:August 13, 2012
Email: webmaster@asmusa.org