APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY by ycPLCf

VIEWS: 7 PAGES: 7

									Michigan State University
Sparrow Health System

APPLICATION FOR FELLOWSHIP
PROGRAM IN NEURO-OPHTHALMOLOGY

Name:
Degree:
Desired Start / Finish Dates: mm/dd/yyyy -- mm/dd/yyyy
Social Security Number: nnn-nn-nnnn
Home Address:




Communication Numbers:
Work:
Home:
Fax:
Email:


Current Affiliation:
Dates: mm/dd/yyyy -- mm/dd/yyyy
Supervisor:
Address:




Medical School:
Dates: mm/dd/yyyy -- mm/dd/yyyy
Address:




                 Page 1 - Michigan State University Sparrow Health System
       APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY
Internship:
Dates: mm/dd/yyyy -- mm/dd/yyyy
Address:




Residency #1:
Dates: mm/dd/yyyy -- mm/dd/yyyy
Director:
Address:




Residency #2:
Dates: mm/dd/yyyy -- mm/dd/yyyy
Director:
Address:




                Page 2 - Michigan State University Sparrow Health System
      APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY
How did you become interested in Neuro-Ophthalmology?




               Page 3 - Michigan State University Sparrow Health System
     APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY
What are your future plans? (Please comment on immediate and long term goals and if
you have a Neuro-ophthalmology position after fellowship completion.):




                Page 4 - Michigan State University Sparrow Health System
      APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY
Please describe research and writing experience in detail below:




                Page 5 - Michigan State University Sparrow Health System
      APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY
Describe your most interesting neuro-ophthalmology patient experience:




                Page 6 - Michigan State University Sparrow Health System
      APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY
Please forward this      Eric Eggenberger, D.O.
application and all      Professor and Vice Chair
documentation to:        Michigan State University
                         Department of Neurology and Ophthalmology
                         138 Service Road, A217 Clinical Center
                         East Lansing, MI 48824
PLEASE SEND THREE LETTERS OF RECOMMENDATION, CURRICULUM
VITAE, MEDICAL SCHOOL DIPLOMA (AND TRANSCRIPT IF AVAILABLE),
EVIDENCE OF COMPLETION OF A RESIDENCY PROGRAM MUST BE
RECEIVED PRIOR TO COMMENCING THE FELLOWSHIP, ECFMG AND TOFEL
CERTIFICATE (if applicable).

PLEASE DO NOT HESITATE TO COMMUNICATE WITH THE DEPARTMENT BY
CALLING 517-353-8122 x130 OR FAX (517) 432-9414.




                Page 7 - Michigan State University Sparrow Health System
      APPLICATION FOR FELLOWSHIP PROGRAM IN NEURO-OPHTHALMOLOGY

								
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