The Methodist Hospital

							                                   The Methodist Hospital
                                    Texas Medical Center
                                       Houston, Texas

                   PGY2- CRITICAL CARE PHARMACY RESIDENCY

                                   APPLICATION FORM


Please type or print in ink.

Date Submitted: ______________________

Name: ________________________________________________________________________________
                 LAST                      FIRST                        MIDDLE

Permanent Address:______________________________________________________________________

                     ______________________________________________________________________
                     CITY                       STATE                        ZIP CODE

Present Address:     ______________________________________________________________________
(if different)
                     ______________________________________________________________________
                     CITY                       STATE                        ZIP CODE

Telephone: Home (_____)______________________          Work (______)_______________________

UNDERGRADUATE EDUCATION

            UNDERGRADUATE COLLEGE                DATES ATTENDED                 MAJOR FIELD OF
                                                                    DEGREE
NAME                    CITY/STATE             FROM      TO                        STUDY




GRADUATE EDUCATION

               GRADUATE COLLEGE                  DATES ATTENDED                 MAJOR FIELD OF
                                                                    DEGREE
NAME                     CITY/STATE            FROM      TO                        STUDY




PGY1 – PHARMACY PRACTICE PROGRAM
NAME                              CITY/STATE       START     END DATE   PROGRAM DIRECTOR/
                                                   DATE                 CONTACT INFO
LETTERS OF REFERENCE
Your application must be supported by three (3) letters of recommendation.

NAME AND TITLE                      INSTITUTION                          ADDRESS/PHONE NUMBER




LETTER OF INTENT
On a separate sheet of paper, describe your reasons for pursuing a PGY2 - Critical Care Pharmacy
Residency. The statement should include your professional interests, achievements, and your five-year
goals as a pharmacist.


APPLICATION REQUIREMENTS
1.    Copy of curriculum vitae (January 5th)
2.    Completed residency application and letter of intent (January 5th)
3.    Three letters of recommendation (January 14th)
4.    All official college transcripts (January 14th)

All forms must be received prior to scheduling interviews. Because a limited number of interview
dates are available, early application to the program is highly recommended.

Please note that an on-site interview is required. All correspondence/questions should be addressed to:

                  Michael G. Liebl, Pharm.D., BCPS
                  Director, PGY2 – Critical Care Pharmacy Residency Program
                  Pharmacy Services
                  The Methodist Hospital
                  6565 Fannin, DB1-09
                  Houston, TX 77030

                  Phone: (713) 441-6973
                  Email: mliebl@tmhs.org




Applicant Signature______________________________________               Date________________________