Stanford University School of Medicine Department of Pathology 300 Pasteur Drive Stanford, CA 94305-5324 APPLICATION FOR FELLOWSHIP IN HEMATOPATHOLOGY Name: Last First Middle Present Address: Telephone #: Permanent Address: Telephone #: Citizenship: Non-medical degrees with dates and universities: Medical School: Degree and date: Postgraduate work including: previous residencies, assistant residencies, fellowships and internships with dates and names of hospitals and schools. List all postgraduate medical courses taken and all internships, residencies or fellowships on the back of this sheet if there is insufficient space below. If you have ever left any course or residency, internship or fellowship for any reason other than the expiration of the usual term, please state the reason. Research projects in progress Application for Fellowship Page 2 of 2 Papers written: States in which licensed: National and State Board Examination (dates and results): Memberships in scientific and professional organizations: Instructions: Applications, curriculum vitae and three letters of reference should be sent to the program director by e-mail or at the street address below: Dita Gratzinger, MD, PhD Assistant Professor Stanford University School of Medicine Hematopathology 650-724-9534 pager 23264 firstname.lastname@example.org Please also copy Krista Tanquary at: email@example.com You may attach a recent 2”X3” photograph if you wish. California laws require that all residents and assistant residents hold a state license. Those who do not have such a license must take and pass the next examination following commencement of service, or obtain licensure by reciprocity with National Boards or another state. Date: _________________ Signature: Stanford University is an equal opportunity, affirmative action employer.