Social Work Fellowship Application

Beth Israel Medical Center

 

Instructions:

1. Submit completed application.
2. Attach current curriculum vitae.
3. Attach a copy of your current state license.
4. Submit three letters of reference, preferably from a social worker, nurse and physician with whom you have worked.
5. Enclose a professional statement (one page or less) of your current involvement with palliative and end-of-life care and your plan for integrating the knowledge and experience from the fellowship training into your future work.

 

______________________________________________________________________________________
Name (Last) First

______________________________________________________________________________________
Address Telephone Number

______________________________________________________________________________________
Fax Number Email Address

______________________________________________________________________________________
Institution Title


List any palliative, pain or end-of-life programs attended/given in the past 5 years.

Program Year

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________


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

______________________________________________________________________________________

______________________________________________________________________________________

 

Publications (if not included in c.v.)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

 

Participation in Social Work Research (if not included in c.v.)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

 

Social Work Licensure

______________________________________________________________________________________
State Serial Number

______________________________________________________________________________________
Date of Issue Date of Expiration

 

Graduates of Foreign Social Work Programs (except Canada)

______________________________________________________________________________________
Type and Date of Certification Date of Expiration

______________________________________________________________________________________
Visa Status Alien Registration Number

______________________________________________________________________________________
Citizenship Date

______________________________________________________________________________________
Language Read Fluently Language Spoken Fluently

 

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

Yes_______ No________

______________________________________________________________________________________
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:

Terry Altilio, LCSW
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
First Avenue at 16th Street
New York, NY 10003
Tel: 212-844-1467
Fax: (212) 844-1503
Email:taltilio@chpnet.org