Integrative Medicine Application

Posted September 26th, 2007 by mmf888

Please fill out this form to submit your application.

Section 1

Name: *

Please enter your first, middle, and last name.

Degrees/Titles:

Street Address:

City:

State/Province:

Postal Code:

Country:

Phone Number:

Fax Number:

E-mail Address: *

Citizenship:

VISA:

VISA Expiration Date

Section 2

Year:

Which year would you like to begin your fellowship?

Other Area:

Section 3

Please submit the following to Adam Rindfleisch

1. A curriculum vitae which includes:

Educational background from undergraduate training onward
Specialty certifications and activities, including those in complementary medicine modalities
Licensure information
Employment history and military service
Honors and awards
Community service and volunteer work
Publications
Presentations
Hobbies, interests, and what gives your life meaning

2. An essay (1000 words or less), which should provide us with:

A sense of who you are - e.g., interests, passions, a description of what gives your life meaning, and how you are caring for your own health
Your reasons for applying for this fellowship
Your past experiences with Integrative Medicine or various "complementary and alternative" treatment modalities
How you would like to use this training in your professional life
Any other information you feel would be appropriate to give

3. A current photograph (need not be a formal portrait)

4. Three references who would be willing to provide letters of recommendation if requested

Utilities