University of California
San Francisco
Hospice and Palliative Medicine Fellowship Application
Please complete the following application and provide the requested information on single-sided
8.5 x 11” pages, without staples. You may mail an original of this application or scan a signed copy and email it to Salina Ng at ;
Salina Ng
University of California, San Francisco
521 Parnassus Ave, Suite C-126
San Francisco, CA 94143-0903
Applying for fellowship to begin academic year:
Name ______
Last First Middle
Institution: ______Department: ______
Permanent Mailing Address
Present Mailing Address
Telephone Numbers: Home _____ Work______
Email address:
Preferred mailing address: home office
Licensed to practice Medicine in State of License No.
Citizenship:______
VISA Type (J1, H1, F1, etc.)______Expiration date:______Permanent Resident?______
How did you learn about the UCSF Hospice and Palliative Medicine Fellowship program?
______
______
The following items are required to complete the application:
1. Personal Statement: Please attach a typewritten personal statement that discusses your career goals and reason for pursuing a fellowship in Hospice & Palliative Medicine.
2. Curriculum Vita: Please attach a recent CV that provides at least the following information:
a. Undergraduate colleges attended, including institution name, location, inclusive dates attended, major and minor discipline(s) studied, and degree received.
b. Graduate or professional schools attended, including Institution name, location, years attended, major discipline(s) studied, and degree received.
c. Postgraduate training, including institution name, location, years attended, major discipline(s) studied, and degree received.
d. Honors and awards, including scholarships.
e. Publications and papers presented at professional meetings.
f. Previous employment, including job title, years worked in the position, and type of work performed.
g. Please account for any gaps in education, training or work.
3. Three Letters of Recommendation:
a. Please provide below the names, titles, addresses, email addresses, and telephone numbers of three individuals who are familiar with your work and whom you have asked to provide recommendations (one of these letters should be from your residency program director). These people should be able to comment on your professional competence and personal characteristics. Please ask these individuals to submit letters on your behalf. We can review your application only after we receive all materials, including letter of recommendations.
1. ______
______
2. ______
______
3. ______
______
4. Please sign your application below (required):
[] I certify that all information in this application is true and no material omissions have been made.
Signature Date
UCSF Hospice and Palliative Medicine Application Form Page XXX/2