Research Fellowship Application

Posted September 13th, 2007 by admin

Please fill out this form to submit your application.

Section 1

Your name: *

Your Address:

State/Province:

Postal Code:

Country:

Telephone Number:

Fax Number:

Email Address: *

Do you have U.S. citizenship?:

Yes

If not, do you have permanent residency (green card)?:

Yes

Section 2

Are you licensed as a clinical provider to see patients?:

Yes

If yes, select which license:

PhD

Other

Specify discipline or degree and discipline:

When do you hope to start a fellowship program?:

(Enter a date in mm-dd-yyyy format, for example, 11-25-2007.)

Section 3

Please submit a curriculum vitae to bruce.barrett@fammed.wisc.edu with your application. Your CV should include:

Education, starting with baccalaureate (institution, inclusive dates, degree/specialty)
Specialty certifications with dates
Licensure (specify states and by whom you are licensed)
(Note: A license to practice in Wisconsin is a requirement for physicians. At the time of your acceptance into the fellowship program, you will be asked to apply to the Department of Regulation & Licensing, Medical Examining Board, 1400 East Washington Avenue, Madison, WI 53702)
Employment since completion of training (employer name/address, dates, position)
Honors and association memberships with dates
Military service, if applicable
Publications, if applicable

Please list three persons whom we may contact for letters of reference

Contact 1

Name/Degree:

Address:

Telephone Number:

Contact 2

Name/Degree:

Address:

Telephone Number:

Contact 3

Name/Degree:

Address:

Telephone Number:

Describe your long-term professional plans and explain how you see your fellowship experience contributing to your future professional activities.

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Explain any additional information that you feel has a bearing on your acceptance into the fellowship program or on your ability to meet the fellowship's requirement

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Utilities

UW Family Medicine

Research Fellowship Application