Affinity Medical Center
Department of Medical Education
875 8th Street N.E.
Massillon, Ohio 44646
Phone 330-837-7239

RESIDENT APPLICATION

Emergency Medicine Otolaryngology/Facial Plastic Surgery
General Surgery Emergency Medicine
Orthopedic Surgery    

GENERAL INSTRUCTIONS: Complete the application in full. If you need additional space to complete your responses, use the area provided at the end of this application. When you have completed the application, click on the SUBMIT button at the end of the application.

The application process is not complete until you send in school transcripts, board scores, a recent head and shoulder portrait and a personal statement to the department of Medical Education.

PERSONAL INFORMATION

First Name: M.I.: Last Name:
Current Address:  
Phone #:
E-Mail:
Permanent Address: (if different from above)  
Phone #:
Contact Person:
Social Security Number: AOA Number:

Contact in case of emergency:

First Name: Middle: Last Name:
Address: City: State: Zip:
Relationship: Phone #:

EDUCATION
Undergraduate

School Name: Address:
Major: Degree: Dates Attending: // to //
Graduation Date:

Medical

School Name Address:
Major: Degree: Dates Attending: // to //
Graduation Date:

Other Graduate

School Name: Address:
Major: Degree: Dates Attending: // to //
Graduation Date:

GRADUATE MEDICAL TRAINING


Internship
Institution: Address:
Type: Program Director:
Dates Attended: // to // Date Completed: //

Residencies

1. Institution: Address:
Type: Program Director:
Dates Attended: // to // Date Completed: //
 
2. Institution: Address:
Type: Program Director:
Dates Attended: // to // Date Completed: //

Fellowship/Preceptorships

1. Institution: Address:
Type: Program Director:
Dates Attended: // to // Date Completed: //
 
2. Institution: Address:
Type: Program Director:
Dates Attended: // to // Date Completed: //

LICENSES/REGISTRATIONS

1. State: Number: Current:
  Program Director: Expiration Date: //
2. State: Number: Current:
  Program Director: Expiration Date: //
3. State: Number: Current:
  Program Director: Expiration Date: //
4. State: Number: Current:
  Program Director: Expiration Date: //

Other Professional

1. State: Number: Current:
  Program Director: Expiration Date: //
2. State: Number: Current:
  Program Director: Expiration Date: //
3. State: Number: Current:
  Program Director: Expiration Date: //

CONTROLLED SUBSTANCES

Federal Number: Current: Expiration Date: //
State Number: Current: Expiration Date: //

PROFESSIONAL SOCIETY MEMBERSHIPS

List all current and pending: ,
, ,
, ,

OTHER INSTITUTIONAL AFFILIATIONS
(Include military service)

1. Name: Address:
Affiliation: From: // to //
2. Name: Address:
Affiliation: From: // to //
3. Name: Address:
Affiliation: From: // to //
4. Name: Address:
Affiliation: From: // to //

DISCIPLINARY AND LIABILITY ACTION

Have there been or are there currently pending, any malpractice claims suits, settlements, or arbitration proceedings involving your professional practice Yes No
If yes, please provide a list indicating for each the date the suit was initiated the name and location of the court, the names of the parties, a brief description of the nature of the claim, and current status on the blank pages at the end of this application.
Have any of the following ever been or are any currently in the process of being denied revoked, suspended, reduced, limited, placed on probation, not renewed or voluntarily relinquished, or have you ever withdrawn or failed to proceed with an application for any of the following? If yes, please provide a full explanation on the blank pages at the end of this application.

Medical license in any state Yes No
Other professional registration/license Yes No
DEA/controlled substances registration Yes No
Academic appointment Yes No
Membership on any hospital medical staff Yes No
Clinical privileges Yes No
Prerogatives/rights on any medical staff Yes No
Other institutional affiliation Yes No
Professional society membership or fellowship/Board certification Yes No
Professional office Yes No
Any other type of professional sanction Yes No
Professional liability insurance Yes No

Have there ever been any felony criminal charges brought against you? If yes, please provide full explanation on additional pages, including resolution of charges. Yes No
To your knowledge, have you ever been the subject of any individual focused review required by PSRO, PRO or similar agency? If yes, please provide full explanation on the blank pages at the end of this application. Yes No

HEALTH STATUS

(If any of the following questions are answered in the affirmative, please provide full explanation at the end of this application.)
Do you have a physical or mental health condition which could affect your ability to exercise the clinical work necessary to perform your intern duties safely and completely? Yes No
Are you currently taking medication/under other therapy for a condition which could affect your ability to perform your intern duties if it were discontinued today? Yes No
Have you at any time during the last ten years been hospitalized or received any other type of institutional care for a health problem? Yes No

Most recent physical examination: Date //
Performed by:

Significant findings:

REFERENCES

Name four medical or health care professionals who have personal knowledge of your current clinical abilities, ethical character, health status, and ability to work cooperatively with others and who will provide specific written comments on these matters upon request from hospital authorities. The named individuals must have acquired the requisite knowledge through recent observation of your professional education over a reasonable period of time, and at least one must have had organizational responsibility for your performance. Preferably the individual should not be related to you by family. Please have these individuals submit a letter of recommendation or complete the evaluation questionnaire to the DME office. (requested sources: preceptors, school faculty, advisors, and a letter from the dean of your medical school is mandatory.) Please include a short personal statement describing your past significant achievements and future plans.
1. Name Address
City, State, Zip Phone //
2. Name Address
City, State, Zip Phone //
3. Name Address
City, State, Zip Phone //
4. Name Address
City, State, Zip Phone //

ADDITIONAL PAGES
Use this space if you need additional space to complete your responses to any part of this application. When you are done, go to the end of the application and click the submit button.

REMEMBER: The application process is not complete until you send in school transcripts, board scores, a recent head and shoulder portrait and a personal statement to the department of Medical Education.