NEW Alternate Entry Path Application - Clinician Educator Pathway

SECTION 1: PROGRAM INFORMATION

Sponsoring Program Name*

Program City and State*

RRC Number*

Department Chair*

Program Director*

SECTION 2: PHYSICIAN APPLICANT INFORMATION

First Name*	Middle Name

Last Name*

Gender*

Male

Female

Birth Date*

Country of Birth *

Medical Degree*

Medical School*

Medical School Country*

Medical Degree Conferral Date*

Anesthesiology Residency Program Name*

Anesthesiology Residency Country*

Name of Foreign Certifying Board*

Address of Foreign Certifying Board*


City*	State*


Postal Code*	Country*

Date Certification Awarded*

Date Applicant Will Enroll in Your Program*

SECTION 3: UPLOAD THE FOLLOWING DOCUMENTS

Applicant’s Curriculum Vitae*

Upload cover letter (on institutional letterhead), signed and dated, by the chair of the anesthesiology department and the program director that sponsors the internationally trained and certified anesthesiologist.

Cover letter*

Detailed four-year plan for applicant*

Upload documentation of the applicant’s anesthesiology certification in a foreign country.

Foreign certification*

Applicant's medical or osteopathic degree*

Upload documentation of the applicant’s anesthesia postgraduate training - Must be comparable in duration to U.S.ACGME-accredited anesthesiology programs

Applicant's postgraduate training*

Upload evidence of one of the following:

a permanent (valid indefinitely) certificate from the Educational Commission for Foreign Medical Graduates
comparable credentials from the Medical Council of Canada
an active license to practice medicine or osteopathy in one state of the U.S. or in Canada that is permanent, unconditional and unrestricted

Applicant's certificate, credentials or license*