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                               INSTRUCTIONS FOR COMPLETING
                                   PROGRAM APPLICATION
GENERAL INSTRUCTIONS FOR APPLICATION:                            Please complete the following application
template electronically. It is important to completely answer each question. Submit one hardcopy of the
application AND either 1) the completed application saved on a blank CD-rom or 2) the completed application
sent via email to

CURRICULUM VITAE: Enclose a hardcopy of your current CV and a copy on the CD-rom or email.

LETTER OF INTENT: Please include professional goals, both short-term and long-term, motivations for
pursuing residency training, and why you are interested in the Temple University Health-System residency
program. Include this as a hardcopy and saved on the CD-rom or email.

TRANSCRIPT: A transcript of all pharmacy courses completed.

PHOTOGRAPH: It is optional to attach a passport size photograph to the application. The photograph will
assist us in recalling you and your interview.

RECOMMENDATIONS: Three specific letters of recommendation are required, one from a pharmacy
employer, one from a clerkship preceptor, and one from another preceptor or pharmacy faculty member. Please
provide each individual writing a recommendation with a copy of the enclosed Residency Applicant
Recommendation Request Form. They are to send their letter of recommendation directly to Temple University
Health-System. Remember that these letters must be received by January 8, 2010.

DEADLINE: All application materials must be received by January 8, 2010.

INTERVIEW: An on-site interview at Temple University Health-System is required. Applicants will be
invited to interview based upon their application, transcript, and letters of recommendation at a mutually
convenient time during late January or February. Interviews are generally scheduled from 7:30 a.m. - 5:00 p.m.
on Mondays and Fridays for 3 candidates each day.

SUBMISSION: A completed application packet includes: 1) Printed copies of application, CV, and
letter of intent 2) CD-rom containing application, CV and letter of intent (or sent via email) 3)
Transcripts, and 4) Letters of recommendation. All materials must by received by January 8, 2010.
Address all materials to:
                              Adrienne L. Au, Pharm.D, M.S.
                              Temple University Hospital Department of Pharmacy
                              3401 N. Broad Street
                              Philadelphia, PA 19140

ASHP MATCH                        PROGRAM DESCRIPTION                                  POSITIONS
  NUMBER                                                                               AVAILABLE
  170913                          PGY1 - TEMPLE UNIV HOSPITAL                               4
  170923                          PGY1 - JEANES HOSPITAL                                    1
                Last                         First                   Middle



    City                 State            Zip

                                                                    Passport Size
[ ]* PRESENT ADDRESS:                                                 (optional)


    City                 State            Zip
                                     ( ) -
    Telephone (home)                      (work)

    E-mail Address

   *Please indicate your preferred mailing address
           during the recruitment process.

                                                     ASHP Matching Number: ______


Describe previous pharmacy work experience emphasizing your specific responsibilities and
experiences (e.g., patient counseling, extemporaneous compounding, unit dose distribution
systems, I.V. admixture compounding, computerization, centralized and decentralized
pharmacy services, automation, etc).

Employer         Dates of         Supervisor         Specific Responsibilities

Pharmacy residents are expected to become licensed interns in the Commonwealth of
Pennsylvania prior to the beginning of the residency. Residents are also expected to complete
the licensure process for Pennsylvania or begin the reciprocation process by the end of July.
Pennsylvania requires 1500 internship hours to take the state board exam. Up to 750 of these
hours may be obtained from Pharm.D. clerkships; the remainder must be obtained outside of
clerkship experience while working as a licensed intern. To be eligible to reciprocate licensure
from another state, you must have been licensed for a minimum of one year in good standing.

List the specific number of internship hours completed and anticipated in the table below.
Total number of hours should be at least 1500. If you will be eligible for reciprocity, list the
date at which you may begin the process.

Reciprocity              No            Yes        If yes, date eligible
                                                  for reciprocity:
Internship Hours
         Clerkship                      Dates            Completed          State     Number of
                                                        (check if yes)                 Hours
Academic Clerkships (Rotations)

Non-Academic Internships

                                                           Total Number of Hours

List all clinical rotations including specific activities and responsibilities for those rotations
completed. If you are a registered pharmacist practicing in a clinical setting, describe your
practice site and your responsibilities.

1.   Describe a specific situation during the past year where you contributed to patient care on
     a clinical rotation.

2.   Describe a specific situation involving conflict among your peers and how you worked to
     resolve the issue.

List the name, address, phone number, fax number, and e-mail address of those individuals
whom you have asked to write a letter of recommendation on your behalf.

1. Pharmacy Employer

2. Clerkship Preceptor

3. Clerkship Preceptor/Pharmacy Faculty Member

I certify that the information submitted in this application is complete and accurate to the best of my

Applicant Signature            Date

                                       RECOMMENDATION REQUEST
To be completed by the applicant
Name of Applicant:                               First Name                   MI           Last Name
(Please print or type)
                                                 Street Address or P.O. Box
                                                 City                     State                Zip
                                                 ( ) -

I waive the right to review this recommendation.
                                                                       Signature of Residency Applicant

To be completed by recommender
Applicants to our residency program are required to have letters of recommendation submitted by persons
who are in a position to evaluate their qualifications for residency training. The recommender is asked to
make an honest appraisal of the applicant's character, personality, abilities, and suitability for a pharmacy
residency. All comments and information provided will be kept in strict confidence.

In your letter of recommendation, please address each of the following:
• How long you have known the applicant and in what capacity?
• What are the applicant's strengths and weaknesses?
• How well is the applicant able to communicate both verbally and written?
• How would you rate the applicant's time management skills?
• How is the applicant able to deal with difficult personalities and situations?
• How is the applicant motivated to perform at a high level in stressful situations?
• What is your recommendation on the applicant’s candidacy?

                                                              Completed request form and letter must
   Signature of Recommender                                   be received by January 8, 2010. The
                                                              letter of recommendation may be initially
   Typed or printed name and title                            sent by e-mail or fax, with a hard copy
                                                              to immediately follow. Send materials to:
                                                                  Adrienne L. Au, Pharm.D., M.S.
   Street Address or P.O.Box                                      Temple University Hospital Pharmacy Services
                                                                  3401 N. Broad Street
   City                        State       Zip                    Philadelphia, PA 19140
                                                                  Phone: 215-707-4642
   E-mail Address                                                 Fax: 215-707-3463
   ( ) -                       ( )     -                          E-mail:
   Telephone                   Fax

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