Untitled Document

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, ACSW
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
First Avenue at 16th Street
New York, NY 10003
Tel: 212-844-1467
Email:taltilio@bethisraelny.org

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