Oklahoma State Medical Association
Observership Program
Application
Applicant Information
Full Name:
Last
Other names you have
used:
Date:
Middle name
Name you would like to be called:
Date of birth:
First
Nationality:
Gender:
MMDDYYYY
M or F
Date of availability to start the observership :
Visa Status:
MMDDYYYY
Will you have a car during your rotations?
Current Mailing address in the
USA:
Street Address
Apartment/Unit #
City
Phone:
()
E-mail Address:
State
ZIP Code
NOTE: Email will be the method of communication between the OSMA and the Applicant
Permanent Mailing Address:
References- Include the names and addresses of 2 physicians that can provide a personal reference
Current Mailing address in
the USA:
Name
Address
State
ZIP Code
City
Current Mailing address in
the USA:
Name
Address
State
ZIP Code
City
Education- List the name of each institution attended. Provide the address of the institution and the dates of attendance.
Use a sheet of paper if needed.
1.
Name and address:
Name
Address
2.
Name and address:
Name and address:
Name and address:
Dates attended
Name
Address
Degree/certificate
Dates attended
Name
Address
4.
Degree/certificate
3.
Degree/certificate
Dates attended
Name
Address
Degree/certificate
USMLE Scores
1.
Step I:
Date
Score
2.
Step II:
Date
Score
3.
Step II CSA:
Date
Score
Page 1
Dates attended
Oklahoma State Medical Association
Observership Program
Application
4.
Step III:
Date
Score
Postgraduate Experience: List the name and address of each program and/or experience attended regardless of whether the
program was completed or credit was received
1.
Name and address:
Name
Address
2.
Name and address:
City
Street Address
Degree/certificate
Dates attended
Apartment/Unit #
City
Name and address:
4.
Dates attended
Apartment/Unit #
Name and address:
Degree/certificate
Street Address
3.
Degree/certificate
Dates attended
Street Address
Apartment/Unit #
City
Degree/certificate
Dates attended
Questions
YES
NO
YES
NO
YES
NO
Have you ever been charged with, or been found to have committed, unprofessional conduct, professional
incompetence, gross negligence, or repeated negligent acts by any medical board, other agency or hospital?
YES
NO
Have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired
practitioner program?
YES
NO
Have you been treated for or had a recurrence of a diagnosed addictive disorder?
YES
NO
Do you have any other condition which in any way impairs or limits your ability to practice medicine safely?
YES
NO
Is any criminal action pending against you?
Are you required to register as a Sex Offender?
Have you ever been denied a license to practice medicine?
If yes, explain:
Complete application packet
Completed application form
Resume or Curriculum Vitae
Evidence of completion of medical education
USMLE Score Reports
ECFMG certificate if available
Copy of visa
Copy of passport- information page, picture page, signature page, inside back cover page
1 passport photo
$250 cashiers check or money order for the non-refundable application fee made out to the Oklahoma State Medical
Association.
Be certain to read the entire observership overview.
*Any document that is written in a language other than English must be accompanied by an original, official translation.
Please mail the completed packet to the following address. Documents that are emailed or faxed will not be accepted.
Oklahoma State Medical Association
IMG Observership
Page 2
Oklahoma State Medical Association
Observership Program
Application
313 NE 50th
Oklahoma City, OK 73105
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. I have read the observer overview and submit my application for the
Observership program.
Signature:
Date:
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