First Name Last Name, M.D., Ph.D.

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First Name Last Name, M.D., Ph.D.DepartmentUniversity/InstitutionApplicant’s Street AddressCity, State Zip Code (Area code) Phone Number (BEST) email@All Items should be listed in reverse chronological order; Arial Font (please make sure all items are listed in the order listed below.) Helpful tips to speed up the process: 1. You can use CTRL+SHIFT+C to copy formatting only and CTRL+SHIFT+V to paste the formatting only (The computer will remember the last paste formatting used, until you copy a new one); 2. Using the Tabs feature helps align the years. Note the Ruler bar at the top of the page on the 5.5” Mark, the tiny right angle is what can be used to set the year alignments. Once set, hitting the tab button automatically pushes the year where you want it. EducationPh.D., (Field), University, City, State/Country mm/yy to mm/yyThesis Title: Advisor:M.D., University, City, State/Country mm/yy to mm/yyB.S./B.A., Major (include Honors), University, City, State/Country mm/yy to mm/yyPostdoctoral TrainingFellowship, University/Institution, City, State/Country mm/yy to mm/yyResidency, University/Institution, City, State/Country mm/yy to mm/yyInternship, University/Institution, City, State/Country mm/yy to mm/yyPostdoctoral Fellow/Scholar mm/yy to mm/yySupervisorDepartment, University/Institution, City, State/CountryLicensureState, License number, exp. mm/dd/yyBoard Certification/EligibilityNational Board of Medical Examiners mm/dd/yyAmerican Board of (Area), Specialty, number mm/dd/yyRecertified (Date), exp. mm/dd/yyAcademic and Leadership Appointments(including professorial, clinical, and university/medical administrative appointments)Associate Professor mm/yy to mm/yyDepartment, University, City, StateTenure mm/yy to mm/yyDirector of Division/Clinicmm/yy to mm/yyDepartment, University, City, StateAssistant Professor mm/yy to mm/yyDepartment, University, City, StateOther Employment (e.g., employment in government, military, industry, consultantships, private/group practice)Rank, U.S. Military Branch, Station, City, Statemm/yy to mm/yyConsultant/Board Member, Company/Institution, City, Statemm/yy to mm/yyPrivate Practice, Facility/Institution, City, State mm/yy to mm/yyHonors and AwardsName of Award, Organization, Significance mm/yyFellow, American College of XX, Significancemm/yy Professional Memberships and ServiceSociety Namemm/yy to mm/yy Member, Committee (Years)Leadership Role, Committee (Years)Educational ActivitiesEducational Administration and LeadershipMember, Committeemm/yy to mm/yyDirector, Programmm/yy to mm/yy Classroom Teaching ActivitiesCourse Name, Role, Number of Students, Subject(s)mm/yy to mm/yyClinical Teaching and SupervisionResponsibility, Location, Level of Effortmm/yy to mm/yyDevelopment of Curricula and Educational MaterialsDescription, Locationmm/yy to mm/yyAdvising and Mentoring(n.b., simply listing learners to whom you have been exposed does not constitute mentorship)StudentsName, Program mm/yy to mm/yyCurrent PositionNature of Advising/Mentoring RelationshipResidents and FellowsName, Program mm/yy to mm/yyCurrent PositionNature of Advising/Mentoring RelationshipPostdoctoral TraineesName, Program mm/yy to mm/yyCurrent PositionNature of Advising/Mentoring RelationshipFacultyName, Program mm/yy to mm/yyCurrent PositionNature of Advising/Mentoring RelationshipGrantsCurrentAgency, Grant Number, Principal Investigator (PI)mm/yy to mm/yyTitleDescription (1 – 2 sentences)Total, direct & indirect costsRole (including % effort)PendingAgency, Grant Number, Principal Investigator (PI)mm/yy to mm/yyTitleDescription (1 – 2 sentences)Total, direct & indirect costsRole (including % effort)CompletedAgency, Grant Number, Principal Investigator (PI)mm/yy to mm/yyTitleDescription (1 – 2 sentences)Total, direct & indirect costsRole (including % effort)Other Active Research Activities and Clinical and Quality Improvement Projects Brief description of the projectmm/yy to mm/yy Technology DevelopmentPatentsPatent title, number, date Devices/Software ApplicationsDescription Publications (List chronologically either newest to oldest or oldest to newest)Peer-reviewed publicationsComplete citation in PubMed formatBooks & ChaptersComplete citation in PubMed formatNon-peer-reviewed publicationsComplete citation in PubMed formatNon-print/Online MaterialsAll authors, title, publication or update date, type of medium, source statement (e.g., URL)Editorial ResponsibilitiesJournal name, rolemm/yy to mm/yy Invited Presentations (For all entries, indicate speaker)(these are invitations to speak at e.g., meetings, symposia, seminars, grand rounds)International(at meetings outside/within the U.S.A. that attract a significant international audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yyNational(at meetings outside/within the U.S.A. that attract a significant nationwide audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yyRegional(at regional/local meetings that attract a statewide audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yyLocal(at local meetings that attract a local audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yy Accepted Oral and Poster Presentations (For all entries, indicate speaker / presenter)International(at meetings outside/within the U.S.A. that attract a significant international audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yyNational(at meetings outside/within the U.S.A. that attract a significant nationwide audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yyRegional(at regional/local meetings that attract a statewide audience)All authors, title of presentation, meeting, location. (Abstract reference if published)mm/yyLocal(at local meetings that attract a local audience)All authors, title of presentation, meeting, location (Abstract reference if published)mm/yyVisiting ProfessorshipsProfessor mm/yy to mm/yyDepartment, University, City, StateAcademic Service UniversityOrganization (e.g. Committee name), role/responsibilitymm/yy to mm/yy Dell Medical School (and other UT Austin Schools and Colleges) Organization (e.g. Committee name), role/responsibilitymm/yy to mm/yy Department Organization (e.g. Committee name), role/responsibilitymm/yy to mm/yyGovernment ServiceOrganization, role/responsibilitymm/yy to mm/yyCommunity ServiceOrganization, role/responsibilitymm/yy to mm/yy ................
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