Geriatrics Center logo

Online Application for
Fellowship Training
in Hospice
and Palliative Medicine

Division of Geriatric and Palliative Medicine, Department of Internal Medicine
The University of Michigan Medical School, Ann Arbor, Michigan 48109


Applying for a Fellowship beginning (Month/Year):  *Accepting applications beginning 2015-16

Name (First/Middle/Last):  


Mailing Address:
	Number, Street, Apt#: 
City, State, Zip Code, Country: Telephone Numbers Where You May Be Reached: Home: Work: Cell (optional): E-mail Address: (required) FAX#: Preferred Method of Contact: Date and Place of Birth:

The following question is optional. This information will be used for statistical
purposes only and will in no way affect your application. 

Do you consider yourself to be a member of any of the following ethnic groups? 
If so, please check the box next to the group you most closely identify with:
African American Asian American Hispanic American Native American

Are you a U.S. citizen? 

To be completed by non U.S. citizens:

Country of citizenship:  

Do you have a U.S. entry visa? If yes, select visa type:  
Visa Number: Permanent Resident?:
NOTE: If English is not your native language, please present documentation (in addition to the language examination of ECFMG) that your knowledge of the English language is sufficient to function as a Fellow in the United States.
The most desirable documentation is a certificate by TOEFL (Test of English
as Foreign Language), Box 899, Princeton, New Jersey 08540, which can be taken
around the world during the months of September, November, February, and May.

Marital Status: 
If married, enter name of spouse (include maiden name): 
Would your acceptance of a position be contingent upon your spouse/significant 
other finding a suitable position in Ann Arbor?   
If yes, please explain: 
List children's names and birthdates (optional):

Education - Undergraduate College or University:

Name/Location of Institution#1:  
Years (inclusive): Degree & Year:
Field of Study: Name/Location of Institution#2:
Years (inclusive): Degree & Year: Field of Study: Education - Graduate or Professional/Medical Schools: Name/Location of Institution#1:
Years (inclusive): Degree: Year:
Field of Study: Name/Location of Institution#2:
Years (inclusive): Degree: Year:
Field of Study: Internship (include name, location, years, specialty area): Residency (include name, location, years, specialty area):

Other Fellowships, Scholarships, Traineeships/Internships:

Awarding Agency#1:  Place:  
Position: Years (inclusive): Awarding Agency#2: Place:
Position: Years (inclusive): Awarding Agency#3: Place:
Position: Years (inclusive) : Awarding Agency#4: Place:
Position: Years (inclusive) : Please list all lapse of training activities following graduation of medical
school, including dates, location and activities.

Employment History Since Graduation:

List chronologically all positions held. Include each year since graduation from
undergraduate college (if applicable) and/or from Medical School:
Name and Address of Employer#1:
Title of Position Held: Dates from/to:
Name and Address of Employer#2:
Title of Position Held: Dates from/to: Name and Address of Employer#3:
Title of Position Held: Dates from/to: Name and Address of Employer#4:
Title of Position Held: Dates from/to:

Military Service:
Branch:  Rank:  
Position: Years (inclusive):

Medical Practice Licensures (please list state, license#, date issued and 
expiration date):

USMLE (United States Medical Licensing Exam) Dates & 3-Digit Scores: 

Step I:  Step II CK :  
Step II CS: Step III: To be completed by foreign medical graduates:
ECFMG Certification is mandatory for those who intend to do clinical work. ECFMG#: Date certified: Clinical Assessment Score:

Medical Specialty Board Certifications:
Name of Board#1:  Year:  Country:  

Name of Board#2:  Year:  Country: 

Extracurricular Activities:

List Memberships in National, Professional, or Related Organizations

Organization/Membership #1:  Year:  
Organization/Membership #2: Year:

Research Experience:

Describe briefly any work you may have done in an area of biomedical research;
indicate outcome of this research and your preceptor. 
List your publications:

Academic Honors, Special Awards (Include Honor, "Awarded by" and Year): 


Career Objective:
How would this Fellowship, if awarded, fit in with your career plans? 
Please answer in detail. Give any additional information to support your application.
Additional Information: 

Documents in Support of Application

Before your application can be considered:
letters of recommendation are required (one required from your Program
Director) with a complete appraisal of all the following areas: medical knowledge,
patient care, professionalism, and interpersonal & communication skills. Applicant
should arrange to have these submitted directly as confidential communications to
the address below. The individuals submitting letters of recommendation are: Reference#1 (Name and Address):
Reference#2 (Name and Address):
Reference#3 (Name and Address):

Personal Statement: 


Send a recent photograph (small) of yourself to the mailing address listed below
or as an attachment (jpg format) to Curriculum Vitae can also be sent an additional attachment to

All documents, information, letters of recommendation, and communications
should be directed to:

Marcos L. Montagnini, M.D.,
Director, Hospice and Palliative Medicine Fellowship Program, VA Ann Arbor Healthcare System 2215 Fuller Road, (11G) GRECC F-224
Ann Arbor, Michigan 48105 Direct inquiries to (734) 845-3066 or by email to
By submitting your application, you are confirming that the above
information is complete to the best of your knowledge.

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