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APPLICATION FOR UCLA ORTHOPAEDIC FELLOWSHIP
TRAINING
Please check
the __ JOINT
REPLACEMENT
fellowship you
are __ MUSCULOSKELETAL ONCOLOGY
applying for: __ PEDIATRIC ORTHOPAEDICS
__ SPINAL DISEASES
__ SPORTS MEDICINE
__
TRAUMA
Fill in year: August 1, 20___
Return
application
and address
all
correspondence
to:
DEPARTMENT OF ORTHOPAEDIC SURGERY
MEDICAL
EDUCATION OFFICE
(please type)
NAME AND
MAILING ADDRESS WHERE YOU CAN ALWAYS
BE REACHED:
_______________________________________________________
___________________
Last First Middle Social Security No.
___________________________________________________________________________
Street City State Zip
TEMPORARY
ADDRESS AND TELEPHONE NO.:
___________________________________________________________________________
Street City State Zip
( ___ ) ( ____ )
Home Telephone Message
DATE OF BIRTH:
______________________________________ __________
month day
year present age
PLACE OF
BIRTH: ____________________________________________________________
City State
or Country
U.S. CITIZEN:
Yes_____ No_____ Country of
Citizenship____________________________
Type
of Visa_________________________________
Expiration
Date_______________________________
HIGH SCHOOL
EDUCATION: _______________________________________________________
School Location Date Graduated
PRE-MEDICAL
EDUCATION: _______________________________________________________
College/University Location
_____________________________________________________
Dates attended Degree Major Subject
_____________________________________________________
College/University Location
_____________________________________________________
Dates attended Degree Major Subject
MEDICAL
EDUCATION:
_____________________________________________________
College/University Location
_____________________________________________________
Dates attended Degree
_____________________________________________________
College/University Location
_____________________________________________________
Dates attended Degree
POSTGRADUATE
TRAINING: Institution Dates
Position
PGYI _________________________________________________________________________
PGYII
________________________________________________________________________
Residency
_____________________________________________________________________
Fellowship _____________________________________________________________________
Other
_________________________________________________________________________
Present Position
________________________________________________________________
RESEARCH EXPERIENCE:
_________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
LICENSED TO
PRACTICE MEDICINE IN:
_____________________
_______________________
state license number
-2-
USMLE SCORES:
Step I Score: _________ Percentile:________ Date Taken___________
Step II Score: _________ Percentile:________ Date Taken___________
EMPLOYMENT
EXPERIENCE: (Please indicate employment
during/and/or following
medical
school)______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
CAREER
GOALS: (What are your practice plans
following completion of your fellowship training?
Private_____
Academic_____ Other_____. Please include
a brief autobiographical sketch and c.v.)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
ACADEMIC AND
HONOR SOCIETIES (e.g., PBK, AOA), DISTINCTIONS, PUBLICATIONS:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
SIGNATURE
_____________________________________
DATE _____________________
-3-
In order to obtain evaluations of
an applicant, it is deemed desirable that letters of evaluation be written and
maintained in confidence. While
nonconfidential letters will be received and carefully considered, confidential
letters may have more utility in the assessment of the applicant's
qualifications and abilities. Therefore,
you are invited, but not required, to sign the following waiver:
I
understand that letters of evaluation concerning me are to be written and
maintained in confidence and I expressly waive any rights I might have to
access to such letters under the Family Educational Rights and Privacy Act of
1974, or any other law, regulation or policy.
DATE:
________________________________________________
SIGNATURE:
___________________________________________
PRINT
NAME: __________________________________________
RETURN
THIS PAGE WITH YOUR COMPLETED APPLICATION
(UCLA is an
Equal Opportunity/Affirmative Action employer.)