ࡱ> PROy #bjbj .>{{lllll8,D&(>>>>%%%%%%%$(*%l%ll>>%[[[Fl>l>%[%[[Vj$@ %>py*Z$ z%%0&$Ti+i+ %i+l %pr[g&%%&i+ 2: TGHMG  Dear Renal Transplant Fellowship Candidate: Thank you for your interest in our recently accredited one-year Renal Transplant Fellowship Training Program in Tampa, Florida. We are currently accepting applications for Program Year 2016 and beyond. In order to complete your application, we request that you submit the following documents: Completed application A CV and Personal Statement Three Letters of Recommendation USMLE Scores (or equivalent) Any Additional Documents which will strengthen your application Application and supporting documents can be mailed to: Debra L. Powell Program Administrator & Fellowship Coordinator Division of Nephrology and Hypertension Department of Internal Medicine University of South Florida Health Morsani College of Medicine 13220 USF Laurel Drive, 4th floor Tampa, FL 33612 We appreciate your interest in our fellowship program and look forward to receiving your completed application.* Sincerely, Debra L. Powell Division Administrator USF Division of Nephrology and Hypertension & Fellowship Coordinator for Nephrology & Hypertension Adult Renal Transplant dpowell@health.usf.edu APPLICATION POST GRADUATE TRAINING PROGRAM POSITION: RENAL TRANSPLANT FELLOWSHIP TRAINING PROGRAM TO BEGIN YEAR 2016 PERSONAL DATA: LAST NAME: ______________ FIRST NAME:__________________ SOCIAL SECURITY No: ______ ___ _____ CITIZEN OF: ______________ BIRTHPLACE: ____________________BIRTH DATE: ____/____/____ Country City/State/Country VISA STATUS ________________ VISA TYPE ________ Expiration Date ___/____/____ PRESENT ADDRESS: _________________________________________ City: ___________________ STATE: ___________ ZIP: _____________ TELEPHONE No: ( ____ ) __________________________ e-mail: _______________ Person through whom you can be contacted: ________________________ __________________________________________________________________(____)_______________ Number Street City State ZIP Phone No Are you currently Board Certified? __________ Specialty: ________________________________ Board Eligible?: ___________________________ EDUCATION: List below in chronological order every college or university you have attended __________________________________________________________________________/___________ School Location Dates Degree/Date Received __________________________________________________________________________/___________ School Location Dates Degree/Date Received __________________________________________________________________________/___________ School Location Dates Degree/Date Received MEDICAL SCHOOL: _____________________________ YEAR GRADUATED: _________________ ADDRESS: ____________________________________________________________________________ Street/PO Box City State ZIP PROFESSIONAL EXPERIENCES: (attach extra sheet if necessary) __________________________________________________________________________/___________ Hospital/Program Nature of Appointment Dates __________________________________________________________________________/___________ Hospital/Program Nature of Appointment Dates __________________________________________________________________________/___________ Hospital/Program Nature of Appointment Dates __________________________________________________________________________/___________ Hospital/Program Nature of Appointment Dates __________________________________________________________________________/___________ Hospital/Program Nature of Appointment Dates LICENSE: Do you hold a valid state license? _____ Yes _____ No State __________ Number __________ List biographical data, papers written, or any item that will strengthen your application. (Attach extra sheet if necessary). ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ INTEREST AREA: (Describe your possible future professional goals or interests: Other subspecialties, transplantation, social medicine, private practice, clinical or basic research, academic career, other practice/field) ___________________________________________________ ___________________________________________________ ___________________________________________________ PHOTO 2 x 3 ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ DOCUMENTATION REQUIRED: Medical School Transcripts. Personal References: (List Names and Addresses). Please request the individuals you listed below to submit personal references in support of your application. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ I certify that the information given in this application is accurate and complete and to the best of my knowledge. I understand that falsification of information will be sufficient grounds for refusal of admission or for dismissal. If admitted to the University of South Florida, College of Medicine, Post Graduate Training Program, I hereby agree to abide by the policies of the Board of Regents and the rules and regulations of the University of South Florida College of Medicine. Signed: __________________________ Date: __________________________ Program Size: The TGHMG-USF One-Year Renal Transplant Fellowship offers 1 fellowship position per year Accredited by the: AST Renal Transplant Fellowship Training Accreditation Committee Anticipated start date: July 1, 2016 Contingent on credentialing clearance & licensure or unlicensed Florida Board of Medicine approval Board Certification: Board certification (or eligibility) in nephrology required For International Graduates: All applications are considered. The University of South Florida sponsors J-1 Work Authorizations (training VISA); however The University of South Florida does not support the H1 B VISA (working VISA) for post-graduate trainees. 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