Application

The individual AOA Neurosurgery Program Director’s team selects the resident for the program. Potential student candidates must apply through the AOA ERAS Program and the AOA National Match. Residents should contact the individual programs and apply using their criteria. To qualify to begin a career that will keep you on the edge of your seat, fighting between life and death you must have graduated from a college of osteopathic medicine accredited by the AOA. You must demonstrate dedication by successful completion of all three sections of the National Board of Osteopathic Medical Examiners (NBOME), COMLEX-USA, USMLE or the FLEX examination(s) by the end of PGY-2. You must have a strong commitment to Osteopathic philosophy, having successfully completed an AOA approved internship (PGY-1), or application for neurosurgical tract/linked internship. You must possess basic skills and achieve an active license to practice medicine and surgery in the state of Neurosurgical Residency by the end of PGY-2. You must hold basic tools, having an active DEA license by the end of the PGY-2. You must demonstrate academic competence required of a Neurosurgical Resident. Finally, and most important, you must demonstrate ethical and moral character, that is required to be a leader.

OSTEOPATHIC POSTDOCTORAL TRAINING APPLICATION

All required fields are marked with an asterisk (*). Please note, however, that some of these fields are required only in certain circumstances. For example, if you state that you did earn or expect to receive a degree from an institution, you will be required to enter what that degree is.

Personal Information *

Full Name: Other Name/Nickname:

Gender Female Ma1e SSN: Birth Date:

AOA Number:

Birth Place: Citizenship Type: Visa Type:

Contact Address *

Street Address:

City: State: Zip Code:

Country:

Contact Phone: Alternate Phone: Contact Email:

Home/Alternate Address *

Street Address:

City: State: Zip Code:

Country:

Contact Phone: Alternate Phone:

Program Selection *

Osteopathic Graduate Medical Education Year:

If Internship:

If Specialty Track, Special Emphasis, or Linked, specify interest:

If Residency, specify interest:

If Sub-Specialty, specify interest:

Military Obligation *

Are you committed to fulfill a U.S. Military active duty service obligation Yes No

If YES, Years of Commitment: Start Month: Start Year:

Non-Medical Undergraduate Education *

For each undergraduate institution you have attended, please provide the following information. This worksheet has space for you to make 2 entries.

Institution: City, State, Country:

Major: Degree expected or earned Yes No Degree:

Degree Date (month/year) :

Dates of Attendance: From (month/year): To (month/year):

Institution: City, State, Country:

Major: Degree expected or earned Yes No) Degree:

Degree Date (month/year):

Dates of Attendance: From (month/year): To (month/year):

Check here if you attended more than two non-medical undergraduate institutions.

Non-Medical Graduate Education *

For each graduate-level institution you have attended, please provide the following information. This worksheet has space for you to make 2 entries.

None

Institution: City, State, Country:

Major: Degree expected or earned Yes No Degree:

Degree Date (month/year) :

Dates of Attendance: From (month/year): To (month/year):

Non-Medical Graduate Education (continued)

Institution: City, State, Country:

Major: Degree expected or earned Yes No Degree:

Degree Date (month/year):

Dates of Attendance: From (month/year): To (month/year):

Check here if you attended more than two non-medical graduate institutions.

Undergraduate Medical Education *

For each medical school you have attended, please provide the following information. This worksheet has space for you to make 2 entries.

Institution: City, State, Country:

Major: Degree expected or earned Yes No Degree:

Degree Date (month/year) :

Dates of Attendance: From (month/year): To (month/year):

Institution: City, State, Country:

Major: Degree expected or earned Yes No Degree:

Degree Date (month/year) :

Dates of Attendance: From (month/year): To (month/year):

Check here if you attended more than two medical undergraduate institutions.

Residencies/Fellowships *

For each internship or residency position you have held. Please provide the following information. This worksheet has space for you to make 2 entries.

None

Specialty: City:

Institution/Program: State/Province: Country:

Program Director:

Supervisor:

Years: Dates of Residency From (month/year): To (month/year):

Reason for leaving:

Specialty: City:

Institution/Program: State/Province: Country:

Program Director:

Supervisor:

Years: Dates of Residency From (month/year): To (month/year):

Reason for leaving:

Check here if you attended more than two residency programs.

Work Experience(s) *

For each work experience position you have had. please provide the following information. This worksheet has space for you to make 2 entries.

None

Organization:

Position: Description:

If no, the reason for leaving:

Dates of Experience: From (month/year): To (month/year):

Work Experience(s) (continued)

Organization:

Position: Description:

If no, the reason for leaving:

Dates of Experience: From (month/year): To (month/year):

Check here if you held more than two work positions.

Leadership, Extra-Curricular, and Volunteer Experiences

For each experience you have had. please provide the following information. This worksheet has space for you to make 2 entries.

None

Organization:

Position: Description:

Dates of Experience: From (month/year): To (month/year):

Organization:

Position: Description:

Dates of Experience: From (month/year): To (month/year):

Please list the honor societies for which you are a member:

Research Experience *

For each experience you have had, please provide the following information. This worksheet has space for you to make 2 entries.

None

Organization:

Position: Description:

Dates of Experience: From (month/year): To (month/year):

Research Experience * (continued)

Organization:

Position: Description:

Dates of Experience: From (month/year): To (month/year):

Publications *

Use also for Poster Sessions/Abstracts/Invited National or Regional Presentations). For each publication/presentation you have had, please provide the following information.

None

Publication/Presentation Citation:

Check here if you have more than two published articles and presentations.

Medical Licensure *

Current Medical Licensure:

Has your Medical License ever been suspended/revoked/voluntarily terminated? Yes No

If YES, please provide explanation:

Have you ever been named in a malpractice case? Yes No

If YES, please provide explanation:

Is there anything in your past history that would limit your ability to be licensed or to receive hospital privileges? Yes No

If YES, please provide explanation:

Have you ever been convicted of a felony? Yes No

If YES, please provide explanation:

Examinations *

For each examination you have taken, please provide the following information.

COMLEX I	COMLEX II	COMLEX III
Score:	Score:	Score:
Passed on:	Passed on:	Passed on:
Failed on:	Failed on:	Failed on:
Awaiting results from:	Awaiting results from:	Awaiting results from:
Will take on:	Will take on:	Will take on:
Will retake on:	Will retake on:	Will retake on:

USMLE I	USMLE II	USMLE III
Score:	Score:	Score:
Passed on:	Passed on:	Passed on:
Failed on:	Failed on:	Failed on:
Awaiting results from:	Awaiting results from:	Awaiting results from:
Will take on:	Will take on:	Will take on:
Will retake on:	Will retake on:	Will retake on:

All Applicants *

Are you able to carry out the responsibilities of an intern or resident the specialties and at the specific training programs to which you are applying including the functional requirements, cognitive requirements, interpersonal and communication requirements, and attendance requirements with or without reasonable accommodations?

Yes

No Response

Was your medical education extended or interrupted?

Yes Reason:

No Response

Limiting Aspects:

Personal Statement *

Personal statement should include medical school awards, hobbies and interests, language fluency, (other than English), other awards and accomplishments, personal strengths, reasons for interest in specified hospital or specialty.

I have reviewed and completed this Osteopathic Postdoctoral Training Application Form. By submitting this form to a postdoctoral training program, I attest that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that the postdoctoral training programs may seek proof or verification from me or third parties of the information provided on this form. I further understand and acknowledge that providing false information on this form is unethical and would constitute cause for my immediate termination from any training program that offers a position to me.