<p>APPLICATION FOR FELLOWSHIP TRAINING UNIVERSITY OF WASHINGTON SEATTLE, WASHINGTON</p><p>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]</p><p>Type of fellowship training desired: ______</p><p>Date of Application: ______Date to begin training: ______Are you interested in a 2nd fellowship year? ______</p><p>Name: ______(last) (first) (middle)</p><p>Social Security No. (circle one): Yes No Date of Birth: ______</p><p>Business Address: ______Home Address: ______</p><p>______</p><p>______Email Address: ______</p><p>Business Phone: ( )______Home Phone: ( )______</p><p>PREMEDICAL EDUCATION</p><p>College Address ___ Date: From-To Degree___</p><p>______</p><p>______</p><p>MEDICAL EDUCATION</p><p>College Address ___ Date: From-To Degree___</p><p>______</p><p>______</p><p>POSTGRADUATE TRAINING</p><p>Position City Institution Type of Service Date: From-To_____</p><p>______</p><p>______</p><p>______</p><p>______</p><p>• 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:</p><p>• ECFMG status and number ____</p><p>• Visa no. ____</p><p>WHAT IS YOUR AMERICAN BOARD OF RADIOLOGY STATUS? ______</p><p>ARE YOU LICENSED TO PRACTICE MEDICINE? ______Where? ______License Number: ______</p><p>MILITARY STATUS: ______</p><p>Are you currently suffering from any disability or illness (mental or physical) which could affect your ability to fully practice medicine?</p><p>______</p><p>HONORS: </p><p>______</p><p>______</p><p>______</p><p>PUBLICATIONS LIST: </p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>SPECIAL TRAINING AND INTERESTS:</p><p>Have you had any special training or experience that could contribute to a research project during your training? ______</p><p>______</p><p>______</p><p> 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. </p><p>Name Title Address ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______Signature (Date)</p>