ࡱ> '` bjbj"9"9 4@S@St ^FFF8NFtFR.ZHZHZHZHZHppprtttttt$!hq]gF pqqZHZH2s2s2sqjZHZHr2sqr2s2s:&x,6xZHNH 0_FqRRx Fz,Á0\xRULrUxUxp"p2sppppprXpppqqqqRRR*FRRRFD.,Z UNIVERSAL HAND SURGERY FELLOWSHIP APPLICATION (if you are sending a picture please attach it to upper right corner) This form has been approved for use by most programs in the Hand Fellowship Match. It may be duplicated. Applications and documents should be directed to the individual program chief. NRMP Candidate No. Fellowship to begin  Name E-mail Add Present Address City/State/Zip Telephone (Work) (Home) Soc. Sec. No. Date of Birth Permanent Address (if different)  Please describe any accommodation needed to participate in the application process:  If hired, can you furnish proof that you are eligible to work in the United States? Yes No (You will be required to provide proof of your identity and authorization to work within three (3) business days after you begin work.) Undergraduate Education College or UniversityDates AttendedDegreeFromTo1. Name Location Honors2. Name Location Honors  Graduate Education (Non-medical) SchoolDates AttendedFromTo1. Name Location Honors2. NameLocationGraduation Date:Honors Mecical Education Medical `SchoolDates AttendedArea of Study DegreeFromTo1.Name  Location Graduation Date: Honors 2. NameLocationGraduation Date:Honors PG Years Hospital - LocationDatesSpecialty - DirectorFromTo1. 2. 3. 4. 5.  National Board ExamsECFMGFlex ExamD.O. Exam# # ##Part #1Date Part #1DateDateScoreDateScorePart #2ScorePart #2ScoreDateScoreDateScorePart #3DateScore Board Certification  Name Year Name Year Licensure  State State State  Number Number Number Any suspensions, restrictions, disciplinary actions? (Please Describe)     Research Experience and Grant Experience Research Projects, PGY2- PGY3- PGY4- Research Fellow, Research Assistant, Research Assistant,  Publications and Presentations (attach copies of publication) 1. 2.  References: Send directly to Program Director Please obtain three professional references including a hand surgeon and the Chief of your residency program.  Military or Government Service Have you ever had any job-related training in the U.S. Armed Services? If yes, please describe:     Special Interests and Abilities Please describe any personal talents, hobbies, or abilities (at your own option, you may limit your response to those interests that you believe may enhance your performance as a Fellow):    Foreign Languages Do you have any foreign language skills that might help you perform the fellowship for which you are applying?  Yes No If yes, please describe:      Personal Statement Address why you wish additional hand surgery training and explain any interruptions in your education or training. Your statement may be attached as a separate sheet. Do not exceed one page. Invitation for interview is dependent upon a completed application, including specified copies and reference letters. In signing this application, I certify that all of the foregoing information is a complete and accurate statement of the facts. I authorize you to investigate and verify all of the information that I have provided in this application. I understand that false information is grounds for immediate dismissal. I agree to notify you promptly of any change in my status. 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