Application

Education

Institution

Medical School

Internship / Residency / Fellowship

References

US Medical Licensing Examination (USMLE) OR Comprehensive Medical Licensing Exam (COMLEX)

Step/Level 1

Yes
No

Step/Level 2

Yes
No

Step/Level 3

Yes
No

Professional Licensure

Military Service

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

I certify that the answers to the foregoing questions are true and complete to the best of my knowledge and belief, and are made in good faith. I give ASMI and VIA the right to contact all persons and/or organizations names to gain information relevant to this application. I understand that any false information, willful or negligent misrepresentation, or failure to disclose any requested information will constitute sufficient grounds for ASMI/VIA to terminate my residency without notice. I acknowledge by my signature that I have read and understand these statements.

In addition to the above completed application, please include:
1. Updated CV
2. Recent photograph
3. Brief personal statement