New York "State 30" Program Application Cover Sheet

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NEW YORK STATE DEPARTMENT OF HEALTH
New York “State 30” Program Application Cover Sheet
Office of Primary Care and Health Systems Management
This cover sheet must be completed by all practice sites proposing to employ physicians under the New York "State 30" J-1 Visa waiver
program for FFY 2017. Please complete and mail, along with all other requested materials, to: New York State Department of Health,
New York “State 30” Program, Corning Tower Room 1695, Albany, New York 12237 (Phone: 518-473-7019).
Please print clearly or type.
I. IDENTIFYING INFORMATION – PHYSICIAN
Last Name ___________________________________ First Name ____________________________________ MI ________
Address _____________________________________________________________________________________________
City __________________________________________________________________ State _________ ZIP
E-mail _________________________ @ _________________________
Phone Number
Specialty ____________________________________________________________________________________________
Home Country ________________________________________________________________________________________
Date of Birth
USMLE/ECFMG
II. ATTORNEY INFORMATION
Last Name ____________________________________ First Name ____________________________________ MI _______
Firm Name ___________________________________________________________________________________________
Address _____________________________________________________________________________________________
City __________________________________________________________________ State _________ ZIP
Phone Number
Fax
E-mail _________________________ @ _________________________
III. PROPOSED PRACTICE SITE INFORMATION
Practice Site Name _____________________________________________________________________________________
Site Contact Last Name ____________________________________ First Name _____________________________________
Address _____________________________________________________________________________________________
City __________________________________________________________________ State _________ ZIP
Phone Number
Fax
Sponsoring Agency (If different from practice site) _____________________________________________________________
Type of Site
Hospital
Diagnostic & Treatment Center (Health Clinic)
Private Practice
Nursing Home
Hospital Extension Clinic
Correctional Facility
Other _________________________________________________________________________________
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