RSA Fellowship Application

RSA FELLOWSHIP NETWORK 2021

FULL NAME & CREDENTIALS:*

First Middle Last Credentials (MD, DO, MBBS, etc...)

DATE OF BIRTH*

GENDER*

MARITAL STATUS*

MEDICAL LICENSURE #1*

Medical License Number Effective Date State / Province / Region Country

DO YOU HAVE MORE THAN ONE MEDICAL LICENSE?*

MEDICAL LICENSURE #2*

Medical License Number Effective Date State / Province / Region Country

MEDICAL LICENSURE #3*

Medical License Number Effective Date State / Province / Region Country

MEDICAL LICENSURE #4*

Medical License Number Effective Date State / Province / Region Country

PRACTICE ADDRESS:*

Street Address City State / Province / Region ZIP / Postal Code Country

PRACTICE WEBSITE:*

HOME ADDRESS:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PERSONAL EMAIL:*

Enter Email Confirm Email

PERSONAL CELL PHONE NUMBER:*

HAVE YOU EVER BEEN CONVICTED OF A CRIME?*

PLEASE EXPLAIN THE CRIME(S) CONVICTION(S):*

ARE YOU CURRENTLY OR HAVE YOU BEEN INVOLVED IN A MEDICAL MALPRACTICE PROCEEDING?*

PLEASE EXPLAIN THE MEDICAL MALPRACTICE PROCEEDING:*

HAVE YOU EVER BEEN SUBJECT TO A PROFESSIONAL DISCIPLINARY PROCESS?*

PLEASE EXPLAIN THE INCIDENT(S) FOR YOUR PROFESSIONAL DISCIPLINARY ACTION:*

DO YOU HAVE ANY MEDICAL/DISABILITY CONSIDERATIONS WHICH MAY AFFECT YOUR ABILITY TO FULFILL THE RSA FELLOWSHIP REQUIREMENTS?*

PLEASE EXPLAIN YOUR MEDICAL/DISABILITY CONSIDERATIONS:*

ARE YOU WILLING AND ABLE TO TRAVEL FOR ONE OR MONTHS PER YEAR DURING THIS FELLOWSHIP PROGRAM?*

PLEASE EXPLAIN WHY YOU ARE UNWILLING/UNABLE TO TRAVEL DURING THE RSA FELLOWSHIP:*

ARE YOU APPLYING TO FELLOWSHIP PROGRAMS IN SPECIALTIES OTHER THAN REFRACTIVE SURGERY?*

PLEASE LIST THE OTHER FELLOWSHIP PROGRAM ARE YOU APPLYING TO:*

DO YOU HAVE ANY FOOD ALLERGIES OR SPECIAL DIETARY CONSIDERATIONS?*

MY FOOD ALLERGIES OR SPECIAL DIETARY CONSIDERATIONS ARE:*

UNDERGRADUATE UNIVERSITY*

Name University City/State Year Begun Year Graduated Degree Received Country

MEDICAL SCHOOL*

Name Medical School City/State Year Begun Year Graduated Degree Received Country

OTHER GRADUATE SCHOOL DEGREE (Optional)

Name Graduate School City/State Year Begun Year Graduated/Graduating Degree Received Country

OTHER EDUCATION DEGREE/CERTIFICATION #1 (Optional)

Name Institution City/State Year Begun Year Graduated/Graduating Degree Received Country

OTHER ACCOMPLISHMENTS OR EXPERIENCE WE SHOULD BE AWARE OF? (Optional)

Please list any other accomplishments you feel we should be aware of here. These would include any honors, awards, research, publications, presentations, professional work experience, etc...

PLEASE DESCRIBE YOUR MOTIVATION FOR PURSUING A FELLOWSHIP POSITION IN THE RSA FELLOWSHIP NETWORK:*

PLEASE PROVIDE THE BEST DAYS(S) AND TIME(S) FOR A WEB INTERVIEW.*

Simply enter the day(s) of the week and the time of day that works best for your schedule. "Example Entry": Sundays from 9:00 AM - 5:00 PM EDT; Wednesdays from 5:00 PM - 9:00 PM EDT; Saturdays from 1:00 PM - 9:00 PM EDT

PLEASE UPLOAD YOU CURRICULUM VITAE AND A HEADSHOT / PHOTO*

Drop files here or

Max. file size: 2 MB.

RSA Fellowship Network Application*

Today, I submit my application to the RSA Fellowship Network. I understand this program provides each Fellow with extensive training in clinical and surgical skills, awareness of the didactic elements of our procedures, and collaboration with the other fellows in the RSA Fellowship Network. There may also be the opportunity for high-quality business training, engagement in technology and innovation and teaching experience, and research.

Email

This field is for validation purposes and should be left unchanged.

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RSA Fellowship Application - June 2021 - July 2022

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