Fellowship Council Matching Process Commitment Dissolution Request The Fellowship Council (FC) requires matching process applicants to offer or accept an appointment if a match occurs. Additionally, the Fellowship Council requires the applicant to start their fellowship in good faith (e.g. with the intent to complete the fellowship program) on the date specified by the program. In limited circumstances, the FC may grant a matching process commitment dissolution for programs and matched fellows who are not able to honor the binding commitment. Matched fellows and programs are not authorized to release each other from the binding matching process commitment. Once a fellow and program have matched, the matched fellow and program must first obtain a matching process commitment dissolution from the FC before matched fellow and program can apply for, discuss, interview for, or accept an alternate position. The decision to grant or deny the matching process commitment dissolution is at the sole discretion of the FC. To initiate a possible matching process commitment dissolution, complete this form in its entirety, which will be sent to [email protected]. Failure to provide all the information requested will delay the processing of your request. Fellow InformationFellow Name* First Last Fellow Phone Number*Fellow Email* Program InformationFellowship Program Name* Program Director Name* First Last Program Director Phone (if known)Program Director Email (if known) Additional InformationReason for Matching Process Commitment Dissolution Request (please choose only one option)* Unanticipated Serious or Extreme Hardship (e.g. change in personal circumstances, financial hardship) Credentialing Issue (e.g. unable to obtain state medical license) Visa Issue (e.g. unable to obtain U.S. / Canadian visa) Decided to change surgical specialty or subspecialty There was a major change since the match, which affects the program’s designation, educational component or case component. (Please provide a detailed explanation) Please provide additional information below.The FC Communications Committee and Board will determine whether a violation by the matched fellow/program has occurred and, if so, the appropriate action for the violation, but please provide additional information regarding your request here. Be as detailed as possible and include timelines where applicable. Have you notified your matched program(s) of your request?* Yes No If yes, who did you notify? By submitting this form, I acknowledge and represent that the information contained in this form is true and correct. I understand and accept that I may be contacted by Fellowship Council staff and/or the Communications Chair for additional information and that Fellowship Council staff and/or the Communications Chair will also contact the program for information on all requests for a matching process commitment dissolution. I understand and accept that the information contained in this form is will be circulated to the Fellowship Council Communications Committee and the Board of Directors for review and that all matching process commitment dissolutions must be approved by the Fellowship Council. Please type your name here: First Last Today's Date* MM slash DD slash YYYY
