Home Phone:
Work Phone:

Address:
Address, Line 2:
City:       State:       Zip:

Applying For: Two-year program / Practicum Year Only (for applicants with MPH)
Schedule: Full-time / Part-time

Date Available to Start:

Education:
List all Colleges and Universities attended, specify degree and dates.

College/University	Degree	Dates

Postgraduate Medical Education:
List all residency programs attended, specify dates, name of program director and department telephone number.

Residency Program	Dates	Program Director	Telephone Number

Licensure Examination:
Please indicate score attained, date of exam and number of attempts.

	USMLE/NBME	FLEX	EDFMG/FEMGEMS
	Part I Part II Part III	Part I Part II Part III	Part I Part II English
Score Attained:
Date of Exam:
Number of Attempts:

Board Certification:
Please list any Boards you have passed or are eligible to sit for:

Specialty	Date of Certification

State Licensure (May be multiple):
If none, please indicate.

State	Date

Personal Statement: Please describe your interest in Occupational and Environmental Medicine. Please comment on any experiences which have motivated you to apply for residency training and what you would like to do with your training after graduation.  (Text area expands to fit your text; write as much as you need.)

References:
Please list 4 individuals who are familiar with your clinical, professional and research skills who we may contact for references.

	Name	Affiliation	Telephone Number
1
2
3
4

Has your license to practice your profession in any jurisdiction ever been revoked, suspended, reduced, not renewed
or voluntarily suspended? Yes / No

Has your staff membership at any hospital or institution ever been revoked, suspended, reduced or not renewed?
Yes / No

Do you presently or have you ever in the past had a physical or mental health condition, including but not limited to
alcohol or drug dependency, that affects or is reasonably likely to affect your duty to perform professional or medical
staff duties appropriately? Yes / No

Have you ever been allowed to resign your position rather than face any charge or investigation on the part of the
medical staff? Yes / No

Have you ever been investigated by any state board of medicine or any medical regulatory board regarding any wrong doing on your part or complaint filed against you? Yes / No

Have you ever been investigated for an alleged DEA violation? Yes / No

Have you ever been excluded from providing services in any federal health care program? Yes / No

Have you ever been named in a malpractice suit? Yes / No

Have you ever been convicted of a felony? Yes / No

Do you have any medical conditions which would restrict your ability to function as a student on campus or travel off campus to distant practicum sites? ** Yes / No

** Information regarding medical conditions is requested only for the purpose of determining appropriate accommodations within the program.**

If you answered "yes" to any of the previous four questions, please provide details:

Submit this application form electronically, then send a copy of your curriculum vitae to cmartin@hsc.wvu.edu, or by regular mail to:

Christopher Martin, MD, MSc
Institute of Occupational and Environmental Health
PO Box 9190, West Virginia University
Morgantown, WV 26506-9190

No other documentation is necessary at this time. Do not send copies of diplomas, residency certifications, transcriptions or letters of recommendation at this time. If applying for the practicum year only, please have a copy of your MPH transcript sent to this office.

By clicking the "Submit" button, THE APPLICANT affirms that the information provided is true and accurate. Permission is granted to contact the references given.