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Nurse Fellowship Application Form

Beth Israel Medical Center

Instructions:

Submit completed application.
Attach current curriculum vitae.
Attach a copy of your current New York State License (applicants must be eligible for New York state licensure).
Submit three letters of reference, two of which should be from medical or nursing Chiefs of Service or supervisors with whom you have most recently served.
Enclose a brief description, of one page or less, of your current involvement with pain or palliative care and how you will utilize the knowledge and experience gained through the Pain and Palliative Care Fellowship in your future work.

PAIN AND PALLIATIVE CARE FELLOWSHIP FOR NURSES

Applying for: Date available:

____________________________________________________________________________________

Name (Last): (First):

____________________________________________________________________________________

Telephone Number:

____________________________________________________________________________________

List any pain management/palliative care programs attended/given in the past 5 years:

Program: Year:

____________________________________________________________________________________

Honors, Awards, Honorary Societies (if not included in c.v.):

____________________________________________________________________________________

Participation in Nursing Research (if not included in c.v.):

____________________________________________________________________________________

Publications (if not included in c.v.):

____________________________________________________________________________________

Nursing licensure:

State: Serial Number: Date of Issue: Date of Expiration:

______________________________________________________________________________

Graduates of Foreign Nursing Programs (except Canada):

Type and Date of Certification: Date of Expiration:

______________________________________________________________________________

Visa Status: Alien Registration Number:

______________________________________________________________________________

Citizenship: Dates:

______________________________________________________________________________

Social Security Number:

______________________________________________________________________________

Language Read Fluently:

______________________________________________________________________________

Language Spoken Fluently:

______________________________________________________________________________

Have you ever been convicted of a crime other than a traffic violation?

Yes

If yes, state each crime, date of conviction, and in which Court:

I declare that the information contained in this application is correct and complete to the best of my knowledge and belief. I understand that Beth Israel Medical Center may request additional information from the above named institutions regarding my candidacy. I understand that misrepresentation of facts called for on this application will be cause for rejection of the application or dismissal after training commences.

Signature:___________________________________ Date:______________________

Applications, letters of reference, and all correspondence should be addressed to:

Marilyn Bookbinder, RN, PhD
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
First Avenue at 16th Street
New York, NY 10003
Tel: (212) 844-1462
Fax: (212) 844-1503