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BIOGRAPHICAL DATA FOR TRAINEES ROTATING THROUGH UCSD MEDICAL CENTER
OR FOR TRAINEES COMPLETING ELECTIVES AT UCSD MEDICAL CENTER

(2011-2012)

The information being sought on this form will be used by UCSDMC in its normal conduct of business relative to your postgraduate training at this institution. Pursuant to the federal Privacy Act of 1974, you are hereby notified that disclosure of your social security number is voluntary. This record keeping system was established pursuant to the authority of The Regents of the University of California, under Article IX, section 9, of the California Constitution. The social security number is used to verify your identity and shall not be disclosed except as permitted by law.

Name ,
Other Last Name Used (e.g., Maiden)
Date of Birth	Social Security Number - -
Home Address
Telephone Number	Pager
E-Mail Address
Organization Name and Address (where you are currently employed or are in training full time)
Residency/Fellowship Specialty (at your institution) Appointment Level (click on one): PGY Level  1 2 3 4 5 6 7 8 9 Start Date of Training (at your institution)
From - To Dates you will train at UCSDMC Specialty
Medical Licensure: (1) License Number Expiration Date State (2) License Number Expiration Date State
Postgraduate training at UCSDMC may be pursued in accordance with the licensure regulations of the State of California. If you are a graduate of a foreign medical school, please direct questions regarding licensure to the department in which you wish to train at UCSDMC.

Number of years completed in all approved residency and clinical fellowship programs in the USA:   Program # of Years Completed Start-End Dates Prior Training         Total years all PGME completed through 06/30/2009

Medical School: Name Degree Conferred Date of Graduation

Foreign Medical School Graduate (school not located in the USA or Canada): I have passed the following exams: USMLE 1 Date   USMLE 2 Date   USMLE 3 Date   FMGEMS Date   NBME Date   Other ECFMG Exam Date

Please return a copy of your current ECFMG certificate with this form to Graduate Medical Education.

Non-Citizen of United States: Class of Visa: Alien Resident J Visa issued by the ECFMG Other - Please designate type Date entered US Intended Length of Stay

Please return a copy of your current visa with this form to Graduate Medical Education.

 

Return this completed form and applicable attachments within five working days to:

Office of Graduate Medical Education and Housestaff Affairs Mail Code 8829 UCSD Medical Center 200 West Arbor Drive San Diego, California 92103-8829