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To participate in our sports medicine fellowship program (within the Department of Family Practice of Hennepin County Medical Center) an applicant must possess a Minnesota license.

The Medical Practice Act issued by the Minnesota Board of Medical Practice stipulates the following: “If a physician has failed a USMLE Step more than three times, he/she is not eligible for licensure in the State of Minnesota.” Consequently, he/she would not be eligible to participate in our sports medicine program, since a Minnesota license is required.

In order to comply with and inform our applicants regarding the Minnesota Statute, we are asking that you complete the following section. Our hope is that this information will ensure that there are no misunderstandings and/or disruptions in training goals for the applicant and for our program.

Please complete the following section for consideration of your application:

DISCLOSURE: UNITED STATES MEDICAL LICENSING EXAMINATION (USMLE)

- OR - if applicable: List NBOME COMLEX scores

Number of attempts

STEP 1: ________________

STEP 2: ________________

STEP 3: ________________

My signature below confirms that the information I have provided is accurate. I understand that if I have failed any USMLE Step more than three times, I am not eligible for licensure in the State of Minnesota; and therefore, I am not eligible to participate in Primary Care Sports Medicine through the Department of Family Practice of Hennepin County Medical Center.

_____________________________________________________

Printed Name

_____________________________________________________

Signature

Also sponsored by: University of Minnesota Methodist Hospital

		Directors: Rob Johnson, MD, CAQ, FACSM & Chuck Anderson, MD, CAQ 5 West Lake Street, Minneapolis, MN 55408 612-545-9250 Fax: 612-545-9259

Overview Welcome General Description Fellow Responsibilities Graduate Demographics Twin Cities Area Info Apply to Us Application Process USMLE Disclosure Experiences Clinical Training Room Curriculum Template Didactics Conferences Event Coverage Benefits Electives Contact Us
	VERY IMPORTANT! (your application *must* include this completed sheet) Click here for printable Word document To participate in our sports medicine fellowship program (within the Department of Family Practice of Hennepin County Medical Center) an applicant must possess a Minnesota license. The Medical Practice Act issued by the Minnesota Board of Medical Practice stipulates the following: “If a physician has failed a USMLE Step more than three times, he/she is not eligible for licensure in the State of Minnesota.” Consequently, he/she would not be eligible to participate in our sports medicine program, since a Minnesota license is required. In order to comply with and inform our applicants regarding the Minnesota Statute, we are asking that you complete the following section. Our hope is that this information will ensure that there are no misunderstandings and/or disruptions in training goals for the applicant and for our program. Please complete the following section for consideration of your application: *DISCLOSURE:* UNITED STATES MEDICAL LICENSING EXAMINATION (USMLE) *- OR - if applicable: List* *NBOME* *COMLEX scores* Number of attempts STEP 1: ________________ STEP 2: ________________ STEP 3: ________________ My signature below confirms that the information I have provided is accurate. I understand that if I have failed any USMLE Step more than three times, I am not eligible for licensure in the State of Minnesota; and therefore, I am not eligible to participate in Primary Care Sports Medicine through the Department of Family Practice of Hennepin County Medical Center. _____________________________________________________ Printed Name _____________________________________________________ Signature THANK YOU!