Northern New Jersey Reconstructive Foot and Ankle Fellowship



North Jersey Reconstructive Foot and Ankle FellowshipApplication deadline for the 2017 – 2018 fellowship is January 13, 2017.Interviews will take place after February 2017.PLEASE FOLLOW ALL INSTRUCTIONS AS OUTLINED BELOW:The following credentials must be sent:Application completed and signedOriginal (certified) medical school transcriptVerification of graduation from medical school(copy of diploma)Verification of graduation from previous US residency program(copy of diploma)Current Curriculum Vitae (CV) and current photographTwo (2) letters of recommendation from attending physicians familiar with the candidate’s performance and one (1) letter from the candidate’s program director (total of 3 letters of recommendation)A copy of the candidate’s surgical logs from residencySend All Materials To:Dr. Beth Loftus, DHSc, MSAdministrative DirectorNorth Jersey Reconstructive Foot and Ankle Fellowship160 Ridge RoadLyndhurst, NJ 07071Phone: 201-939-9098Fax: 201-939-5614For additional information, please contact Dr. Beth Loftus by phone at 347-993-6166 or email at loftuselizabeth@North Jersey Reconstructive Foot and Ankle Fellowship ApplicationMichael Subik, DPM, DABPS, FACFAS, CMETBoard Certified in Foot, Ankle, and Reconstructive Rearfoot SurgeryNorth Jersey Reconstructive Foot and Ankle Program DirectorInstructions: Please write legibly or type this application. Complete all requested information. Your application will not be reviewed until our Fellowship Committee receives all of the information listed on the cover page. To learn more about our practice and the Fellowship program, please visit our website at .Your full legal name:___________________________________ Today’s Date:_____________Date of Birth:____________________ Place of Birth:__________________________________Driver’s License #:__________________________ State Issued:_____ Expiration Date:_______Social Security Number:____________________________ Martial Status: _________________Home Address:____________________________________ Home Phone: __________________Work Address: ____________________________________ Work Phone: __________________Email Address: ____________________________________ Fax Number: _________________EDUCATION:Undergraduate Institution: _________________________________ Degree: ________________Location: ______________________________________ Dates Attended: __________________Podiatry School: ________________________________ Degree: _________________________Location: ______________________________________ Dates Attended: __________________BOARDS:National Board of Podiatric Medical ExaminationsPart IPart IIPart IIIDate TakenScorePOSTGRADUATE TRAINING:Residency: ____________________________________ Degree: _________________________Location: _____________________________________ Dates Attended: __________________Type of Residency: PMSR__________ PMSR – RRA__________ Other___________Residency: ____________________________________ Degree: _________________________Location: _____________________________________ Dates Attended: ___________________Type of Residency: PMSR__________ PMSR – RRA__________ Other___________MEDICAL LICENSES:State:_______ Number:___________________ Issue Date:____________ Expiration:________State:_______Number:___________________ Issue Date:____________ Expiration:________At the time of this application, are your licenses in good standing with no restrictions? ___yes ___no If no, please explain. _______________________________________________REFERENCES:1. Name:______________________________ Position: ________________________________Work Address:___________________________________ Phone:_________________________Email Address:___________________________ Length of time known:____________________2. Name:______________________________ Position: ________________________________Work Address:___________________________________ Phone:_________________________Email Address:___________________________ Length of time known:____________________3. Name:______________________________ Position: ________________________________Work Address:___________________________________ Phone:_________________________Email Address:___________________________ Length of time known:____________________Has a medical malpractice judgment been entered against you or has a claim against you been settled, or is one pending / in progress? _____ yes _____ noIf yes, please explain the details of the case on a separate piece of paper and attach it to your application.Why did you decide to apply for the North Jersey Reconstructive Foot and Ankle Fellowship?I certify that the entries set forth in this application are true and accurate.Print Name: _________________________________________________Signature: __________________________________________________Date: ______________________________________________________For Office Use Only:Date Received:__________________ By: _________________Application Complete: ________ Yes ______ NoNotes: ................
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