RESEARCH FELLOWSHIP by IthZ436

VIEWS: 3 PAGES: 6

									                                UNIVERSITY OF ILLINOIS AT CHICAGO
                                  DEPARTMENT OF NEUROSURGERY
                                RESEARCH FELLOWSHIP APPLICATION

Affix Photo:




PERSONAL DATA
Name (LAST, FIRST, MIDDLE):


Current Mailing Address:
                                                 Daytime Phone #:
                                                 Evening Phone #:
                                                 Email:
                                                 Fax:
                                                 Pager #:

Alternative, Permanent Address:
                                                 Day Phone:
                                                 Evening Phone:
                                                 Email:




                           No                    If not US citizen, Immigration/Visa Status?

I am a citizen of:




Revised 10/24/05                                                                               1
                                      UNIVERSITY OF ILLINOIS AT CHICAGO
                                        DEPARTMENT OF NEUROSURGERY
                                      RESEARCH FELLOWSHIP APPLICATION

Undergraduate Education (College/University)
List your college experience in chronological order (most recent first).
                School                            Major            Dates Attended                        Degree Earned / Date Granted
                                                                    From (mo/yr) to (mo/yr)




Medical School
List your medical school experience in chronological order (most recent first).
                     School                           Dates Attended                  Degree Earned / Date granted
                                                       From (mo/yr) to (mo/yr)




Other Graduate School
List your graduate level experience in chronological order (most recent first).
               School                         Specialty         Dates attended                     Degree Earned / Date Granted
                                                                 From (mo/yr) to (mo/yr)




Post-Graduate Education (Residency)
List your post-graduate level experience in chronological order (most recent first).
School /Medical Facility/ Institution             Specialty            Dates attended                  Degree Earned / Date Granted
                                                                         From (mo/yr) to (mo/yr)




Other Experiences or Employment since Medical School and/or Graduate School
List your experience in chronological order (most recent first).
School / Medical Facility / Institution  Experience/Employment         Dates Attended                  Certification (if applicable) /Date
                                                                       From (mo/yr) to (mo/yr)         Granted




Revised 10/24/05                                                                                                                             2
Use this page only. Do not exceed this page, single-spaced. Do not use font size smaller than 10 points. This form is defaulted to 12-point size font.

Career Objectives:




Prior/Current Research Activities:




Prior/Current Research Grants:




Publications:




Other Relevant Information:




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                                                          STATEMENT OF INTENT
Research Interest in Neurosurgery:
Use this page only. Do not exceed this page, single-spaced. Do not use font size smaller than 10 points. This form is defaulted to 12-point size
font. Your statement should be organized and concise.

Please provide a statement including the following:
• Ar of p       ly     r ( f known)
•T     fr      3 months  6 months  1 year  >1 year  Other, please specify:
•




Revised 10/24/05                                                                                                                                   4
                                             UNIVERSITY OF ILLINOIS AT CHICAGO
                                               DEPARTMENT OF NEUROSURGERY
                                             RESEARCH FELLOWSHIP APPLICATION



LETTERS OF REFERENCE
Please provide the names and addresses of 3 personal references from whom you should request letters of recommendation. These individuals must be
physicians/scientists with whom you have worked closely in the past and/or present.


1. Name and Title:



  Institution:

  Address:                                                                        Phone:

2. Name and Title:



  Institution:

  Address:                                                                        Phone:

3. Name and Title:



  Institution:

  Address:                                                                        Phone:




Revised 10/24/05                                                                                                                                    5
                                 UNIVERSITY OF ILLINOIS AT CHICAGO
                                   DEPARTMENT OF NEUROSURGERY
                                 RESEARCH FELLOWSHIP APPLICATION

SUPPORT DOCUMENTS
Enclosed are the following:

      Photo                                              NOT      lo d r h follow g, b          u …

      College Transcript                                     _______________________________
                                                               _______________________________
      Medical School Transcript
                                                              _______________________________
      TOEFL (for foreign graduates only)                      _______________________________

      CV/Resume                                              _______________________________
                                                               _______________________________
      Research Grants (if applicable)

      Three (3) Letters of Reference                     For every document you cannot provide, you must
                                                          provide an explanation on a separate page with the
      L r of Good          d g fro      ppl   ’          appropriate document label. This is necessary to
       institution                                        satisfy the completion requirements for your file.



I understand that my file will not be reviewed until
you have received all of the above documents.




I certify that the information in this application is true and complete and that I have not withheld information
that might affect my qualifications for a research fellowship in Neurological Surgery in any way. I understand
that any misrepresentation in this application and its accompanying documents may be cause for immediate
termination of my applicatio pro         or fu ur      ploy        u hor       C’ D p r         of N uro urg ry o
contact any or all of my former employers, educational institutions and/or other persons or organizations that
may have information relevant to my application. I understand that any information obtained will be treated as
confidential information.

Signature: __________________________________________________ Date: ________________________




Revised 10/24/05                                                                                                    6

								
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