Surgical Critical Care Fellowship Application
Orlando Regional Medical Center



In order to begin the application process and be considered for possible interview, please complete the following online application. In addition to completing this form, we require submission of the following documents before an interview can be scheduled. These documents may be either emailed to the program director, submitted to our office by fax (407.648.3686) or sent by U.S. mail or other carrier to the address below. Once your application is complete and has been reviewed by the program director and department faculty, you will be contacted and an interview date will be arranged.

Michael L. Cheatham, MD, FACS, FCCM
Program Director
Surgical Critical Care Fellowship
Department of Surgical Education
Orlando Regional Medical Center
86 West Underwood Street
Suite 201
Orlando, Florida 32806


DOCUMENTATION REQUIREMENTS FOR APPLICATION:
  • A recent photograph
  • A copy of your current curriculum vitae
  • A copy of your USMLE scores
  • A copy of your ECFMG certificate (if applicable)
  • Copies of both your undergraduate and medical school transcripts
  • A copy of your medical school diploma
  • Three letters of recommendation (one of which must be from your chairman)


    Please answer ALL of the questions on the fellowship application
    I am applying for the following Fellowship Year (select one):
    2008-2009 2009-2010 2010-2011

    Fellowship Program (select one):
    Surgical Critical Care Fellowship (one year)
    Combined Surgical Critical Care / Trauma Fellowship (two year)

    Personal Information
    Name: Last First Middle

    Contact Information:
    Street
    City
    State
    Zip Code
    Country
    Daytime Phone
    Evening Phone
    Email address

    Permanent Address: (Name of person through whom I can always be contacted)
    Contact Name
    Street
    City
    State
    Zip Code
    Country
    Phone

    Social Security Number
    ECFMG Registration (if applicable):

    Citizenship:
    U.S. Citizen
    Other (please list) Visa Status: Permanent J-1 H-1


    Undergraduate Education
    College Name
    City
    State
    Country
    Degree
    Month/Year of Matriculation
    Month/Year of Graduation
    Awards

    Graduate (Medical School) Education
    Medical School
    City
    State
    Country
    Month/Year of Matriculation
    Month/Year of Graduation
    Alpha Omega Alpha (AOA)? (check if yes)

    Internship & Residency
    Internship Program:
    Hospital
    City
    State
    Country
    Dates

    Residency Program:
    Hospital
    City
    State
    Country
    Dates

    Residency 2: (if applicable)
    Hospital
    City
    State
    Country
    Dates

    Personal Statement


    Service Obligations (National Health Service, Armed Forces, etc...):
    I am not required to fulfill any service obligations.
    I am committed to fulfill a service obligation beginning (enter Month/Year)



    Please ensure that all of the above information is correct
    before clicking the "Submit Application" button.
    Incorrect information will delay the application process.