Name: _________________________________________ Year Graduated: _________
Address: _________________________________________
_________________________________________
_________________________________________
Telephone:
Office ( ) _______________________
Email Address: __________________
Home ( ) _______________________
1. Type of Examinations Passed:
| | Yes | Score | No | Date |
| V.Q.E. | | | | |
| E.C.F.M.G. | | | | |
| National Boards | | | | |
| F.M.G.E.M.S.I. | | | | |
| F.M.G.E.M.S.II. | | | | |
| U.S.M.L.E. I | | | | |
| U.S.M.L.E. II | | | | |
| C.S.A. | | | | |
| USMLE Step 1 | | | | |
| USMLE Step 2 CK | | | | |
| USMLE Step 2 CS | | | | |
2. Residency Completed:
Hospital: ____________________________________________________
Address: ___________________________________________________
____________________________________________________
Area of Speciality: ____________________________________________
Date Started: ________________________________________________
Date Completed: ______________________________________________
3. Fellowship Completed:
Hospital: ____________________________________________________
Address: ____________________________________________________
____________________________________________________
Area of Speciality: ____________________________________________
Date Started: ________________________________________________
Date Completed: _____________________________________________
4. Licensing Exams Passed:
| | Yes | No | Date |
| F.L.E.X. | | | |
| U.S.M.L.E. III | | | |
Sub-Speciality: _____________________________________
6. Licensure:
5. Board of Certification:
Speciality: _____________________________________
Name (s) of States:
1 ________________________________
2 ________________________________
3 ________________________________
4 ________________________________
*** Please Return Completed Questionnaire to P.O. Box 989, Santa Teresa, NM 88008 ***
