My Application> Common Application Form
Last_Name, First_Name (AAMC #); Common Application Form
General Information
Name:
Last_Name, First_Name
ID#:
0000000000
Previous Last Name:
XYZ
Gender:
Female
School:
College Name
Email:
First_Name@email.com
Couples Match Notification:      No
AAMC ID:
AAMC #
NRMP:
Yes
SSN:
Citizenship:
Foreign National
    
Visa type: 
H-1, H-1B, H-2, H-3 temporary worker
AUA #:
Birth Place:
Home city, India
Birth Date:
01/12/1975
USMLE ID:
0-000-000-0
NBOME ID:

Race:
No Answer

Ethnicity:
No Answer
 
Present Mailing Address:
Permanent Mailing Address:
Street Address
City, State    zip
Street Address
City, State    zip
PreferredPhone #:     home phone
Phone:     home phone
Alternate Phone #:     cell phone
Pager:    
 

Military Service Obligation?
No
Years:  
     Military Branch:  
Other Service Obligation?
No
Description:  

Felony Conviction?
No
Reason:  
No Limitations?
Yes
Description:  

Examinations
Examination Status Date
USMLE Step 2 CS (Clinical Skills)
Passed 
07 / 2002 
USMLE Step 2 CK (Clinical Knowledge)
Passed 
01 / 2002 
USMLE Step 1
Passed 
07 / 2001 

Medical Licensure
ACLS:
Exp. Date:
PALS:
Exp. Date:
DEA REG. #:
Exp. Date:
 
Board Certification:
Yes
Name:
State Medical Council
Medical Licensure Problem:
No
Ever named in a Malpractice Suit?
No
Past History?
No
  

State Medical Licenses
Type
Number
State
Exp. Date
None 
  
  
 

Education Commission for Foreign Medical Graduate Certification
Are you certified by the ECFMG?
Yes
 Certification Date: 12 /2002

Medical Education
Institution & Location
Dates Attended
Degree
Date of Degree
College Name
 , India
09 / 1994 -  05 / 2000
Yes, MBBS
10 / 2000
Medical Education Extended or Interrupted?
No
  

Medical School Honors/Awards
None  

Membership in Honorary/Professional Societies
None  

Graduate Education
None

Undergraduate Education
Institution & Location
Dates Attended
Degree
Degree Date
Field of Study
abc College - Home city, India
07 / 1992 - 03 / 1994
No
 
Biology

Residencies/Fellowships
Institution
Program Director
Program Supervisor
Dates Attended
Years
Specialty
Medical College
College Name, , India
Dr. Pillai
Dr. Rao
06 / 1999 - 05 / 2000
1
Internal Medicine
Reason for Leaving:
After the successful completion of one year of compulsory rotating internship in Internal Medicine, General Surgery, Pediatrics, Obstetrics and Gynecology, Family Planning, Social and Preventive medicine, Emergency Medicine and Orthopedic Surgery.

Work Experience
Organization
Position
Dates
University of *********, Emergency Psychiatry
Clinical Externship
03 / 2002 -  04 / 2002
Description
I did a one month externship in Emergency Psychiatric Services with Dr. Mathew,M.D., Associate Professor and Director of Mood Disorder Research Program. He provided me with an opportunity to gain experience in emergency management of patients. I participated in the morning discussions which involved comprehensive crisis assessment and appropriate referrals for persons requiring urgent psychiatric services. I was actively involved in the history taking and quick physical examinations, as well as, counseling for alcohol and substance abuse. With the help of him, I learned to approach patients in an empathetic and supportive manner, to make them more comfortable and further encourage them to get actively involved in the care.
Reason for Leaving:
Inorder to prepare for the upcoming Step2 CS and USMLE Step 3 examinations.
University of *********, Dept of Psychiatry
Clinical externship
01 / 2002 -  03 / 2002
Description
I was fortunate to receive a clinical externship position at University of ********* Department of Psychiatry, under Dr. Fryrear, M.D.,Professor and Director of Inpatient Psychiatric Services. He was keen on providing me with an opportunity to work with patients, both in an inpatient, as well as, outpatient setup. During my association with the university hospital, I was trained in all major aspects of clinical practices in the US. I was actively involved in the history taking, physical examination and management discussions. Under his guidance, I learned the importance of leadership and teamwork for effective patient management. I participated in all clinical discussions, grand rounds and journal clubs and even had the opportunity to train the medical students newly posted in our unit. I also attended the ethics meetings and psychiatric conferences. Along with Dr. Fryrear, I authored three articles, two of them have been accepted for publication, and one is under consideration.
Reason for Leaving:
To continue externship in Emergency Psychiatric Services under Dr. Mathew

Volunteer Experience
Organization
Position
Dates
********* Train Accident 
Physician 
06 / 1999 - 08 / 1999
Description
The ********* Train Accident happened in June, 1999 taking 54 lives, and injuring 230 people. The majority of the victims were rushed to the Emergency Department of College Name Medical College. I actively volunteered to help these people with the emergency first aid as well as further treatment for the injured, including investigations and transfering them to appropriate wards.I was also involved in providing emotional support for the families of the deceased.
Org for Industrial,Spiritual &Cultural Advancement 
Active volunteer 
03 / 1998 - 12 / 1998
Description
Organization for Industrial, Spiritual & Cultural Advancement(OISCA) contributes to humanity's environmentally sustainable development through a holistic approach emphasizing the interconnectedness of agriculture, ecological integrity and the human spirit. I keenly participated in the Eco Development Project to promote awareness about nature conservation and conduct forestation programs in the campus and adjoining facilities. In addition to these programs, I was also involved in campus cleaning projects and in organizing camps.
Blood Donors Forum 
Volunteer 
10 / 1997 - 05 / 2000
Description
I was a member of the Blood Donors Forum-College Name Medical College Chapter. As a team member, I was involved in motivating the public to donate blood, and promoting awareness among them of HIV and Hepatitis. I was also involved in organizing blood grouping camps.
Pain & Palliative Care Clinic 
Physician 
01 / 1997 - 12 / 1998
Description
I was an active volunteer at the Pain and Palliative Care Clinic which is an outpatient clinic in College Name Medical College for patients with advanced cancer and for patients in chronic pain. The clinic is housed in Department of Anesthesiology and is run with the help of other sister disciplines. I helped the patients attending the clinic get medical treatment for their symptoms; their emotional and psychological problems are also being attended to in an atmosphere of love and care. Since most of the patients are very poor, medicines are also given free of cost. On an average, the clinic sees 65 patients a day, six days a week.

Research Experience
None

Publications
Myname, Fryrear , Primary Psychiatry , Watch out for Olanzapine-Induced Hyperglycemia(under consideration) ,
Myname, Fryrear , Psychosomatics , Blood dyscrasia:twice with quetiapine and once on ziprasidone(awaiting publication) ,
Myname, Fryrear , Psychosomatics , Leukopenia: Is it associated with divalproex and/or quetiapine?(awaiting publication) ,

Language Fluency (Other than English)
Tamil, Hindi and Malayalam.

Hobbies & Interests
Reading books, listening to music and spending quality time with my family.

Other Awards/Accomplishments
National Merit Scholarship awarded for excellence in Predegree examination conducted in 1994.

Certification
I certify that the information contained within my ERAS application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for a residency position, or if employed, may constitute cause for termination from the residency program, and will also result in expulsion from ERAS and investigation by the AAMC per the attached policy (pdf file).
Certified by:
Last_Name, First_Name
Date:
09/02/2002