Physician Assistant/Nurse
Practitioner Training Program in
Psychiatry
Contact Information
Name
Street Address
City ST ZIP Code
Home Phone
Cell Phone
E-Mail Address
Interests
Tell us why you are interested in applying for the training program.
Special Skills or Qualifications
Have you graduated from an accredited program?
Physician Assistant Program
 Graduated Date:
 Expected Date:
Nurse Practitioner
 Graduated Date:
 Expected Date:
Do you have an unrestricted Texas license?
Physician Assistant Program
 Yes
 Expected Date:
Nurse Practitioner
 Yes
 Expected Date:
Have you taken a certification exam?
Physician Assistant Program
 Yes/Passed Date:
 Expected Date:
Nurse Practitioner
 Yes/Passed Date:
 Expected Date:
Person to Notify in Case of Emergency
Name
Street Address
City ST ZIP Code
Home Phone
Alternate Phone
E-Mail Address
Agreement and Signature
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that
if I am accepted as a trainee, any false statements, omissions, or other misrepresentations made by me
on this application may result in my immediate dismissal.
Name (printed)
Signature
Date
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion,
national origin, gender, sexual preference, age, or disability.
Upon completion of this form, please submit via email to kary.blair@ttuhsc.edu . Please include a current
copy of your curriculum vitae or resume, three letters of recommendation and an unofficial copy of your
transcripts from your physician assistant or nurse practitioner program.
Thank you for completing this application form and for your interest in training with us.