application for fellowship - Hematopathology

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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
[email protected]
Please also copy Krista Tanquary at: [email protected]
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.
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