www.paacs.net	

	

PAACS TRAINEE APPLICATION

Please e-mail this completed application and scans of all requested documents by April 15 to: admissions@paacs.net.  
Upon receipt of this application there will be more materials requested which are due by May 15.
Please send this application only ONCE.

Please note: If you are over 35 years old, your chances of being accepted into a PAACS program will be considerably less than for younger candidates, but you may complete the process of applying to PAACS if you wish. If you are over 40 years old, we regret that we will not be able to process your application.

Instructions:  Move from gray blank to blank using the tab key.  If there is a box, click to select “x” to signify the correct answer.  
If there is a rectangle, then type or print your answer in that rectangle.  If you are unable to complete this electronically, you may print, complete, scan and email the document.  

GENERAL INFORMATION
Full Name:      		
(SURNAME (Grandfather’s), First Name, Middle (Father’s), Other)	Date of Birth:      	
Name you go by:      				Gender/Sex:  Male    Female	
Mailing or Street Address:      
	Nationality:      			
	
Phone number(s) (include country code):      	Religion:      	
	
E-mail:      	Date of Marriage:      	
Languages in which you are fluent (list all):      		
Spouse’s Name:      							Date of Birth:      	
Child’s Name:      							Date of Birth:      	Adopted 	
Child’s Name:      							Date of Birth:      	Adopted 	
Child’s Name:      							Date of Birth:      	Adopted 	
Child’s Name:      							Date of Birth:      	Adopted 	
Child’s Name:      							Date of Birth:      	Adopted 	

ACADEMIC HISTORY 
Dates			School or University Name and Address			Diploma Received	
From      to          	     							     	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	

Formal Medical Training After Medical School:	
Dates			Hospital Name and Address				Certification	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	

Employment Since Graduation:	
Dates			Name and Address					Position Held	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	
From       to          	     							     	

Do you have any obligations to any organization (hospital, a government, church, military, mission agency, etc.) that you are required to complete either currently or at some date in the future?    Yes  No   If you answered yes, please provide a description of any obligation (attach supporting documents if any).      

Your Selection of Residency Program Preferences

I am applying for General Surgery:  	 Yes, check the boxes of the programs you are willing to attend if selected.
	 No, skip to Subspecialty Programs or Post Fellowship Training

General Surgery Programs (5 year program)
VERY IMPORTANT: Only check “Yes” for programs that you are interested and WILLING to attend if you are selected by that program.  If you are NOT WILLING to attend a specific program, check “No”.
 
Kibuye Hope Hospital (Burundi)	 Yes   No	
Harpur Memorial Hospital (Egypt) Egyptian Nationality Only	 Yes   No	
Soddo Christian Hospital (Ethiopia) Ethiopian Nationality Only	 Yes   No	
Bongolo Hospital (Gabon)	 Yes   No	
Kijabe Hospital (Kenya)	 Yes   No	
Litein Hospital (Kenya)	 Yes   No	
Tenwek Hospital (Kenya)	 Yes   No	
Malamulo Adventist Hospital (Malawi)	 Yes   No	
Mbingo Baptist Hospital (Cameroon)	 Yes   No	
Galmi Hospital (Niger)	 Yes   No		
Arusha Lutheran Medical Centre (Tanzania)	 Yes   No		
Nkhoma Mission Hospital (Malawi)                                                                                                               Yes   No	
Hopitaly Vaovao Mahafaly Mandritsara (Madagascar)                                                                              Yes   No	
Hospital of Hope (Togo)                                                                                                                                   Yes   No	

Subspecialty Programs
I am applying for the Orthopaedic Residency (5 year program)
 		Soddo Christian Hospital (Ethiopia)						 Yes   No	
		Kijabe Hospital (Kenya)								 Yes   No	
		Tenwek Hospital (Kenya)							 Yes   No	
I am applying for the Pediatric Surgery Residency
		BethanyKids/Kijabe Hospital (Kenya)						 Yes   No	
I am applying for Anesthesiology Training 
		Kijabe Hospital (Kenya)					   	                              Yes   No	
I am applying for OBGYN Training 
		Tenwek Hospital (Kenya)	
I am applying for Surgical Endoscopy Training
		Tenwek Hospital (Kenya)	
I am applying for Neurosurgery Training
		Tenwek Hospital (Kenya)				  	                              Yes   No	

Continued next page

Post Fellowship Training (General Surgery Diploma Required)
I am applying for the Cardiothoracic Surgery Fellowship (3 year program)
 		Tenwek Hospital (Kenya)							 Yes   No	
I am applying for the Head and Neck Fellowship (1 year program)
		Mbingo Baptist Hospital (Cameroon)		                                                           Yes   No	
I am applying for the Plastic Surgery Fellowship (3 year program) 
                             AIC Kijabe Hospital (Kenya)                                                                                                  Yes   No	

I have asked my hospital, church, or other institution to financially support me during my surgical training.  		 Yes  No    Their response was      
Please accept my application to become a trainee with PAACS.  I hereby certify that I am in good health and that the statements in the Health Certificate Form I completed are true.  I hereby certify that all information I have provided is correct to the best of my knowledge and belief. 

Your Printed Name:       						Date of Application:      	
ADDITIONAL REQUIREMENTS

Your application must include the following to be complete:  
•	Copy of Birth Certificate 
•	Copy of Current Passport and/or Government ID
•	Copy of Medical Diploma 
•	Copy of Medical License and evidence that it is current
•	If Married, Copy of Marriage License
•	Completed PAACS Health Certificate 
•	Transcripts from Medical School, Post Graduate, Master Exam
•	Good Quality, Passport Style, Digital Color Photograph (scanned, attached to an email or mailed) 

You are responsible to translate all documents which are not in English into English, and to have them notarized.
All required forms and documents must be submitted before May 15 of the current year in order to be considered for January of the following year. 
 
Once the above information is completed, you will be notified by e-mail of the status of your application and any need for further documents before you are scheduled for one or more interviews with the PAACS faculty.  Following your interview, your acceptance or rejection by the PAACS faculty will be final and is not subject to appeal.

Please e-mail this completed application and scans of all requested documents by April 15 to: admissions@paacs.net.  
Upon receipt of this application there will be more materials requested which are due by May 15.

The Pan-African Academy of Christian Surgeons (PAACS)
_______________________________________________________________________________________________

FOR APPLICANT’S USE ONLY

Please keep a list of dates as you e-mail documents to PAACS.  The deadline for having all your information (this application and subsequent materials) to PAACS is May 15.  You are strongly encouraged not to wait until the last minute to get this information to us as it often takes several months to obtain it.

Send the completed list to admissions@paacs.net.   This will assist both you and PAACS in making sure that all documents are received by the appropriate deadline.

Document	Date e-mailed to PAACS	
Birth Certificate		
Passport or Government ID		
Medical Diploma 		
Medical License 		
Marriage License		
PAACS Health Certificate 		
Transcripts from Medical School, Post Graduate, Master Exam		
Color Photo