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Emory University Orthopedic Residency

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					                                         Emory University
                                       Orthopedic Residency


                                Emory University Division of Physical Therapy
                                            Admissions Office
                                       1462 Clifton Road, Suite 312
                                            Atlanta, Ga. 30322




APPLICANT INFORMATION:

Application deadline: October 1, 2010

Legal name: ___________________________ ____________________ __________________
                                Last                               First                        Middle

Date of birth:___________________                      Male         Female

Current address:

_________________________________________________                          _________________________
            Number and street                                                     Apt number

____________________________ ______________                                    __________________
City                                                 State                          Zip Code



Home Telephone: ( ______ ) _________________________

Cell Phone: ( _____ ) ____________________________

E-mail address: ___________________________________

EDUCATIONAL BACKGROUND

What is your highest academic degree? _________________________________

Please list the titles of previous research projects and the school/institutional affiliation:




Do you hold a current license to practice Physical Therapy in Georgia?                 Yes      No

If no, when do you anticipate obtaining your Georgia PT license? _________________
                                    Emory University
                                  Orthopedic Residency



Do you hold licenses to practice physical therapy in other states? ___________________


Do you have other board specialty certifications?         Yes      No

If yes, please list other board specialty certifications and the date of certification:



______________________________________________________________________________


Name      of     college Year(s)           Degree                Major               Graduation Date
attended:                Attended




WORK EXPERIENCE:

Please list two positions that you have held within the last five years:

Position                                   Employer                        Dates




______________________________________________________________________________

RESIDENT’S STATEMENT OF INTEREST

Please answer the following questions and submit with the Emory Orthopedic Residency
Application. Your answers should be submitted in type-written format, double spaced.

1. Why have you chosen to apply to the Emory Orthopedic Residency Program?
2. What are your personal professional goals and objectives?
                                 Emory University
                               Orthopedic Residency


3. How do you feel that this program will assist you in meeting your personal goals and
objectives?
4. Through the achievement of you personal goals, how do you envision your
role/contribution to the physical therapy five years from now?


I certify that the above information that will be submitted to the Emory University, Division of
Physical Therapy is correct to the best of my knowledge.



________________________________________________                 ________________
Signature of applicant                                           Date

				
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