Surgical Critical Care Fellowship Application

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:



Please answer ALL of the questions on the fellowship application

Fellowship
I am applying for the following fellowship year 2011-2012

2012-2013

2013-2014

2014-2015

Fellowship Program 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.