"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: email@example.com Applicant Signature______________________________________ Date________________________