Application for Fellowship Training

APPLICATION FOR FELLOWSHIP TRAINING UNIVERSITY OF WASHINGTON SEATTLE, WASHINGTON

Please return completed form to: Neuroradiology Fellowship Program, University of Washington Department of Radiology, Box 357115, Seattle, Washington 98195- 7115. Please address any questions to Bill Freeberg, Program Coordinator: (206) 598-5130, [email protected]

Type of fellowship training desired: ______

Date of Application: ______Date to begin training: ______Are you interested in a 2nd fellowship year? ______

Name: ______(last) (first) (middle)

Social Security No. (circle one): Yes No Date of Birth: ______

Business Address: ______Home Address: ______

______

______Email Address: ______

Business Phone: ( )______Home Phone: ( )______

PREMEDICAL EDUCATION

College Address ___ Date: From-To Degree___

______

MEDICAL EDUCATION

College Address ___ Date: From-To Degree___

______

POSTGRADUATE TRAINING

Position City Institution Type of Service Date: From-To_____

______

• 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. FOREIGN MEDICAL GRADUATES - Please complete the following two items:

• ECFMG status and number ____

• Visa no. ____

WHAT IS YOUR AMERICAN BOARD OF RADIOLOGY STATUS? ______

ARE YOU LICENSED TO PRACTICE MEDICINE? ______Where? ______License Number: ______

MILITARY STATUS: ______

Are you currently suffering from any disability or illness (mental or physical) which could affect your ability to fully practice medicine?

______

HONORS:

______

PUBLICATIONS LIST:

______

SPECIAL TRAINING AND INTERESTS:

Have you had any special training or experience that could contribute to a research project during your training? ______

______

 On a separate sheet please attach a personal statement (narrate your reasons for seeking fellowship training, your long range objectives in radiology and the amount and type of subsequent training you desire).  Please mail or e-mail a current copy of your curriculum vitae.  Please include a copy of your medical school diploma, and copies of your USMLE or LMCC scores. REFERENCES • Please list three references. Please include your residency program director if possible. Please contact them and ask each to write a letter of reference at this time. Please address letters to James Fink, MD, Neuroradiology Fellowship Program Director, Department of Radiology, Box 357115, University of Washington, Seattle, Washington 98195-7115.

Name Title Address ______

______

______Signature (Date)