METHODIST HOSPITALS OF DALLAS
FAMILY PRACTICE RESIDENCY PROGRAM
at METHODIST CHARLTON MEDICAL CENTER
APPLICATION FOR EXTERNSHIP IN FAMILY PRACTICE
BEGINNING DATE DESIRED:__________________ENDING DATE:_____________
1. Name_________________________________________________________________________
(Last) (First) (Middle)
2. Present address:_________________________________________________________________
3. Permanent address:______________________________________________________________
4. Telephone ( )_________________________5. Alternate Contact Number________________
6. Date of Birth:________________________Place of Birth:________________________________
7. Medical School__________________________________________________________________
7a. Expected Date of Graduation____________________________________
8. Non-Medical Training and Experience (include dates)____________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9. Academic Honors and Publications__________________________________________________
______________________________________________________________________________
10. Physical disability, if any__________________________________________________________
11. ENDORSEMENTS AND REQUIRED LETTERS: (Students responsibility for contact )
1) An official medical school transcript.
2) One letter of recommendation from a medical school faculty member, preferably from your
Department of Family Practice.
12. On a separate sheet, please provide a personal statement which describes your professional and
personal interests, externship training objectives and career goals.
13. Applicants will be contacted further after review of this application and supportive documents.
14. Forward application to: Becky Trlica, Recruitment Secretary
Family Practice Residency Program
3500 W. Wheatland Road
Dallas, Texas 75237-3498
15. Signature________________________________________Date___________________________
(If you have any questions, please contact: Becky Trlica, Recruitment Secretary, at 214-947-5402,
or toll-free 1-800-856-1076. Our fax number is 214-947-5425.)