Kettering Health Network - Grandview Medical Education

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Application for OGME 2 & Above

Residencies Fellowships

Personal Information

Name:

AOA#:

Date of Birth:

Email:

Current Address:

City:

State: Zip:

Phone:

NPI#:

Visa Sponsorship Needed? Yes No

Certifications

BLS	Exp Date:
ACLS	Exp Date:
PALS	Exp Date:
ATLS	Exp Date:

Licensure

License #:	State	Exp Date:
License #:	State	Exp Date:
License #:	State	Exp Date:

Have you ever had your medical licensure suspended / revoked/ voluntarily terminated? Yes No
If yes, please explain:

Are you currently board certified? Yes No
If yes, please list your certification and expiration:

Have you ever engaged in private practice? Yes No
If yes, please list:

Have you ever been named in a malpractice suit? Yes No
If yes, please explain:

Have you ever been convicted of a felony? Yes No
If yes, please explain:

Have you ever been convicted of a misdemeanor? Yes No
If yes, please explain:

Medical School

Institution:
Address:

City, State, Zip:
Phone #:
From:	To:
Dean:
Major & Degree:
Minor:
Publications
Awards / Memberships
Was your medical school training interrupted? Yes No If yes, please explain:
Did you successfully complete training? Yes No

OGME-1 Training

Institution:
Address:

City, State, Zip:
From:	To:
DME:
Program Director Name:
Phone #:
Medical Education Contact Person:
Medical Education Contact:	Phone Number: Email:
Specialty:
Publications
Was your training interrupted? Yes No If yes, please explain:
Did you successfully complete training? Yes No

Residency Training

Institution:
Address:

City, State, Zip:
From:	To:
DME:
Program Director Name:
Phone #:
Medical Education Contact Person:
Medical Education Contact:	Phone Number: Email:
Specialty:
Publications
Was your training interrupted? Yes No If yes, please explain:
Did you successfully complete training? Yes No

How to Complete Your Application

Complete files require:

Transcripts
Dean's letter of recommendation
Three (3) professional letters of recommendation
DME letter (Residents)
Curriculum Vitae

Personal statement
Copy of board scores
Copy of medical school diploma
Copy of OGME-1 Certificate / Letter
Copy of Residency Certificate - if applicable

By checking this box I certify that everything within this application is accurate and complete.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, disability,
veteran status, or any other legally protected status.

Physicians Only
Employees Only

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