PEDIATRIC CARDIOLOGY FELLOWSHIP PROGRAM

Application for 2011-2012 Academic Year

University of Washington Affiliated Hospitals

Seattle, Washington

Date: Name:

Address: Work Phone:

Home Phone:

Cell Phone:

Pager:

Email:

Social Security Number: Sex: M F Date of Birth:

Citizenship:

If you graduated from a foreign medical school, do you have an ECFMG certificate: YES NO

ECFMG Number: Type of Visa: Visa Number:

PRE-MEDICAL EDUCATION

College and location / Major area of study /

Dates of Attendance

/ Degree and Date Awarded
MEDICAL EDUCATION

INTERNSHIPS, RESIDENCIES, AND FELLOWSHIPS

Name of Hospital / Location / Specialty / Dates Begun and Completed

The University of Washington provides equal opportunity in education on the basis of race, color, national origin, and sex in accordance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments and Sections 799A and 855 of the Public Health Service Act. 1

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Pediatric Cardiology Fellowship Application Page 2

References

·  One letter from the director of your residency program.

·  Two letters from faculty or professional staff of your medical school or hospitals where you have worked in the past five years.

Additional recommendations may be added. List names of all references below:

Name and Title Type of Contact Institution, City, State

Membership in Professional Societies

Are you licensed to practice medicine? Y N

In which state(s)?

______

Signature Date

Please include with this application the following:

·  3 Letters of Recommendation

·  Curriculum Vitae

·  Personal Statement

·  Passport style photo

Copyright 2005 © Pediatric Cardiology. All rights reserved.

The University of Washington provides equal opportunity in education on the basis of race, color, national origin, and sex in accordance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments and Sections 799A and 855 of the Public Health Service Act.

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