.: Westchester General Hospital :. - Internship/Residency ONLINE Application


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Westchester General Hospital and Southern Winds Hospital are accredited by the Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic Association (AOA). Click on the logo below for further information on our HFAP Seal of Excellence accreditation status.

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I. Personal Information

Step 1 of 9.


First Name
Middle Initials
Last Name
Social Security Number (xxx-xx-xxxx)
Email Address
Marital Status	SingleMarried
Gender	FemaleMale
Number of children	01 23 4more than 4
Program Desired	Internship Residency-PGY-2 Residency-PGY-3
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
Specialty Rotation Desired

Permanent Address

Permanent Street
Permanent City
Permanent State (2 character code)
Permanent Zipcode (xxxxx)
Permanent Phone # (xxx-xxx-xxxx)

Present Address

Is your present address the same as your permenant address above?	YesNo
Present Street
Present City
Present State (2 character code)
Present Zipcode (xxxxx)
Present Phone # (xxx-xxx-xxxx)
Do you have impairments (physical, mental, or medical) which might interfere with your ability to function in an intern or resident capacity?	YesNo
If you chose yes above, please explain

II. Pre-Osteopathic Education

Step 2 of 9.

School 1

School Name
School City
School State (2 character code)
Years Attended
Degree Granted

School 2

School Name
School City
School State (2 character code)
Years Attended
Degree Granted

School 3

School Name
School City
School State (2 character code)
Years Attended
Degree Granted

III. Osteopathic Education

Step 3 of 9.


School 1

School Name
School City
School State (2 character code)
Years Attended

School 2

School Name
School City
School State (2 character code)
Years Attended
Anticipated Graduation Date (mm/dd/yyyy)
National Board
Completed Parts	IIIIII

IV. State Board Licenses

Step 4 of 9.


License 1

Issuing State (2 character code)
License Number
Issue Date (mm/dd/yyyy)

License 2

Issuing State (2 character code)
License Number
Issue Date (mm/dd/yyyy)

V. Post-Graduate Training

Step 5 of 9.



Institution Name
Street
City
State (2 character code)
Zip Code (xxxxx)
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
Director Of Medical Education
Director Phone # (xxx-xxx-xxxx)
Do you have any military or Public Service obligations upon completion of training?	YesNo
Geographics/ Demographics of area in which you wish to practice
Principal type(s) of Practice Interest
Rotations Completed
Rotations Pending

VI. References

Step 6 of 9.


Reference 1

Reference Name
Reference Street
Reference City
Reference State (2 character code)
Reference Zipcode (xxxxx)
Reference Phone # (xxx-xxx-xxxx)

Reference 2

Reference Name
Reference Street
Reference City
Reference State (2 character code)
Reference Zipcode (xxxxx)
Reference Phone # (xxx-xxx-xxxx)

Reference 3

Reference Name
Reference Street
Reference City
Reference State (2 character code)
Reference Zipcode (xxxxx)
Reference Phone # (xxx-xxx-xxxx)

VII. Emergency Contact

Step 7 of 9.


Emergency Contact Name
Contact Street
Contact City
Contact State (2 character code)
Contact Zipcode (xxxxx)
Contact Phone # (xxx-xxx-xxxx)

VIII. Additional Information

Step 8 of 9.


ACLS Training	YesNo
PALS Training	YesNo
Date Of Expiration (mm/dd/yyyy)
Additional Data

IX. Applicant's Certification and Agreement

Step 9 of 9.

PLEASE READ CAREFULLY BEFORE SUBMITTING THE APPLICATION

I certify that the information contained in this application is correct to the best of my knowledge and understand that any falsification, misrepresentation or omission on this application is grounds for disqualification for a training position at our institution.

I agree to comply with the Hospital and Internship/Residency rules, regulations and policies, and acknowledge that these rules, regulations and policies may be changed, interpretation withdrawn, or supplemented any time and without prior notice to me.

I agree to have a physical examination and drug screen as required for my position and understand that any offer is contingent upon my passing the physical examination.

I authorize the hospital through its agents or representatives to consult with persons or organizations referenced in this application and with all others who may have information bearing on my educational qualifications for the position I have requested, my character and my ethical qualifications.

I release from liability all individuals and organizations who provide information in good faith and without malice at the hospital's request concerning my qualifications.

I understand that the signature below shall have the same legal effect as if made under oath.




Signature (type name in full)
Social Security Number: (xxx-xx-xxxx)

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