Clinical Volunteer Application

Graduate Medical Education

Aldrich Room 124
Rhode Island Hospital
593 Eddy Street
Providence, RI 02903

Print Legibly or Type ALL Responses

PERSONAL INFORMATION

MD DO PhD DMD/DDS - DPM

Name:
Maiden/Other Name:

Current Affiliation or Program: _____________________________________

Address:_______________________________________________ Office Phone No.:

_______________________________________ Fax No.: _____

Pager No.: ______

Home Phone No.:

Social Security #: _______________________

Medical Specialty: _______________________

Medical Staff Sponsor/Contact: ___________

Clinical areas in which you will participate:

EDUCATION

Medical/Dental/Podiatric/Osteopathic School
School Grad. Date Degree
Address
School ________________________________ Grad. Date ____________________ Degree______________________
Address

Graduate School
School __________________________________ Grad. Date_____________________Degree______________________

Address

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TRAINING

Residencies & Fellowships

1. Name of Hospital __________________________________ Dates:
Type of Program ______________________________
Address_________________________________________________________
2. Name of Hospital ________________________________ Dates:

Type of Program ______________________________

Address_________________________________________________________
3. Name of Hospital ________________________________ Dates:

Type of Program ___________________________

Address_______________________________________________________
4. Name of Hospital _______________________________ Dates:

Type of Program ______________________________

Address_______________________________________________________

LICENSURE Please attach copies of each ofthefollowing:

Medical Licenses
State of______________________________ License # __________________ Exp. Date____________

State of____________________________ License # _________________ Exp. Date ____________

(List additional licenses on attachment)

PROFESSIONAL REFERENCES

Name: Telephone: Fax:________________

Adress:
Name: Telephone: Fax:________________
Adress:

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I MISCELLANEOUS INFORMATION
Are you a citizen of the United States? Yes: No: Please respond to the following:
Citizenship:_____________________________
Type of VISA:___________________ Expiration Date:____________
PLEASE PROVIDE A PHOTOCOPY OF YOUR VISA
Foreign Medical School graduates: (Please include copy of certificate)
Are you registered with the ECFMG? Yes:__________ No:
Have you passed the ECFMG exams? Yes:__________ No:
ECFMG # ___________________ Date:
ADDITIONAL INFORMATION

I hereby certify that the facts set forth above are true and complete. I agree to abide by all hospital rules and
regulations as they now or may exist. I understand that I must complete a communicable disease record and
obtain a PPD Test (Mantoux test). I agree to maintain strict patient confidentiality.

Applicant’s Signature: Date: