Fellow of IC-OS (FICOS) Application - International Cardio Oncology Society

Fellow of IC-OS (FICOS) Application

Medical Education:
First Name *Enter the First Name
Last Name *Enter the Last Name
First Name *		Last Name *
Have you passed the IC-OS Board Certification Exam? *You must pass the IC-OS Board Certification Exam before applying for FICOS status	Yes No
Street Address *
City/Province *
State
Country *		Zip/Postal Code *
Email Address *
Institutional Affiliation *
Gender
Please indicate which Fellows status you are seeking

Name of Medical school *
Date of Graduation *
Upload Copy of Diploma *
Upload a Copy of Medical License *
Cardio-Oncology Fellowship (if applicable)

Name of Institution for Fellowship
Name of Fellowship Program Director		Program Director Email Address
Dates of Fellowship
Description of Cardio-Oncology experience:

Copy of Resume or Short CV (Two pages or less) *
List of Publications *3 for Clinical Excellence; 10 for Scientific Excellence [5 of which must be first or last author], 2 for Practice Excellence
OR Upload List of Publications
Upload References
For Clinical or Scientific Excellence- 2 supporting letters: One supporting letter from an IC-OS Board Member or Supervisory Committee member One supporting letter from a Fellow of the IC-OS. For Practice Excellence- 2 supporting letters: One supporting letter from a Board Certified member of a related professional Society. One supporting letter from a member of one of the IC-OS committees
Reference #1 *
Reference #2 *
For Practice Excellence only:

Letter(s) certifying Hospital Appointment(s)
Letter(s) certifying Hospital Appointment(s) b

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