Harvard Medical Toxicology Fellowship Application Form

Harvard Medical Toxicology Fellowship Application Form

All application materials, including letters of recommendation and transcripts, must be received by the due date of November 1st, 2017 to ensure consideration for the 2018-2019 academic year.

PERSONAL DATA:
Name: / (type your name here)
Current Mailing Address: / (type your current address here)
Permanent Mailing Address: / (type your permanent address here)
Telephone Numbers: / Day: (type your day time phone number here)
Evening: (type your evening phone number here)
Email Address: / (type your complete email address here)
Social Security Number: / (enter your social security number)
Date of Birth: / (enter your date of birth here)
Place of Birth: / (enter your place of birth)
EDUCATION:

Degrees

School

Date Completed

Undergraduate: / (enter undergraduate school name here) / (enter date here)
Medical School: / (enter name of medical school here) / (enter date here)
Other: / (enter school name here) / (enter date here)
POST GRADUATE TRAINING:

Title

/ Institution / Date Completed

PGY 1

/ (enter institution name) / (enter date here)

PGY 2

/ (enter institution name) / (enter date here)
PGY 3 / (enter institution name) / (enter date here)

Other

/ (enter institution name) / (enter date here)
Residency Training (please check one): / Pediatrics
Emergency Medicine
National Board Certifications: / Step 1: (enter year and score)
(Enter Year and Score) / Step 2: (enter year and score)
Step 3: (enter year and score)
Licensure (List state and year): / State: (enter state) Year: (enter year)
Awards, Honors, and Memberships in Professional Societies:
Academic and Committee Memberships:
List of names and addresses of three professional references:
1) (enter name)
(enter address)
(enter city, state, zip code)
(enter phone number)
2) (enter name)
(enter address)
(enter city, state, zip code)
(enter phone number)
3) (enter name)
(enter address)
(enter city, state, zip code)
(enter phone number)

CHECKLIST FOR COMPLETION OF APPLICATION:

Completed and signed application (including photo)

A personal statement of professional goals and reasons for desiring fellowship position

Curriculum Vitae

Please have each individual send a letter of recommendation to:

Michele Burns, MD, MPH

Fellowship Director, Medical Toxicology

Boston Children's Hospital

MailStop 3025

300 Longwood Ave.

Boston, MA 02115

Requested Dean’s letter/Official Transcript from medical school.

Date requested: (enter date)

PLEASE COMPLETE APPLICATION ONLINE

PRINT, SIGN, AND MAIL TO THE ADDRESS ABOVE

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