University of Virginia Health System
Pharmacy Residency Programs
Application Form
Please checkto which residency program you are applying:
PGY1 Pharmacy
PGY1 Pharmacy/ PGY2-Health System Pharmacy Administration
PGY1 Pharmacy/ PGY2 Drug Information
PGY2 Critical Care Pharmacy
PGY2 Drug Information
PGY2 Health System Pharmacy Administration
PGY2 Oncology Pharmacy
PGY2 Pharmacy Informatics
Name:
FirstMiddleLast
E-mail: ______
Current Address:
(Street)
(City, State, Zip Code)
(Phone)
Permanent Address:
(Street)
(City, State, Zip Code)
(Phone)
If you are/were required to register for the Selective Service, have you done so?□ Yes□ No
Are you a veteran who received an honorable discharge and (i) has provided more than 180 consecutive days of full-time active duty in the armed forces of the United States or reserve components thereof, including the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs? □ Yes □ No
Are you a veteran who has been honorably discharged and has a service-connected disability rating fixed by the U.S. Veterans Affairs? □Yes □ No
Have you previously filed an application with the University of Virginia Health System or any of its affiliates?
□ Yes□ No
Do you have any relatives currently employed with UVaMedicalCenter? If yes, please provide names and departments.
□ Yes□ No
Have you ever been disciplined, separated from employment, or left employment while under investigation for abuse, neglect, or sexual exploitation of a patient, child, or incapacitated adult? □ Yes □ No
For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States? □ Yes □ No
Have you ever been convicted of a crime other than a minor traffic violation? If yes, please explain.□ Yes□ No
College of Pharmacy (Must be ACPE-accredited):
Graduation Date:
If applying for a PGY2 program, indicate your PGY1 Residency Program (must be ASHP-accredited)
Site:
Program Director:Completion date:
References: Please list the names, titles, and addresses of the individuals whom you have requested
to send letters of reference.
2.
3.
Have you applied to the ASHP Resident Matching Program?Yes No
Residency Match Number:
Date of completion Signature of applicant
Send completed application materials to:
Residency Selection Committee: Name of residency to which you are applying
University of Virginia Health System
Department of Pharmacy
P.O. Box 800674
Charlottesville, Virginia 22908-0674
Attn: Name of Residency Program Director (program director names can be found here)
*Application materials must be received by January 4, 2012 for the applicant to be considered for an interview.
Required Application Materials:
Completed application
Three letters of recommendation
Official copy ofSchool of Pharmacy transcripts
Current Curriculum Vitae
Letter of Intent which must, at a minimum, include:
- Why you wish to enter a residency program
- Your future goals in pharmacy