Palomar Health Fellowship Application Form
Instructions: Please provide the following information in the spaces provided below.
Last Name: __________________________________
Phone Number: _______________________________________
First Name: __________________________________
E-mail Address: _______________________________________
Middle Initial: ________________________________
Address: ___________________________________________________________________________________________
City: _______________________________________
State: ______________
Zip Code: ______________________
Education:
List all colleges and universities attended (undergraduate/graduate) and please send corresponding official graduate transcript.
Institution Name: ___________________________________________________________________________________________
City: ___________________________________________________
State: _______________________________
Degree/Major: _________________________________________ Graduation Year: ________________ GPA: ______________
Institution Name: ___________________________________________________________________________________________
City: ___________________________________________________
State: _______________________________
Degree/Major: _________________________________________ Graduation Year: ________________ GPA: ______________
Institution Name: ___________________________________________________________________________________________
City: ___________________________________________________
State: _______________________________
Degree/Major: _________________________________________ Graduation Year: ________________ GPA: ______________
☐ Yes ☐ No
By the start of the Fellowship will you have received your graduate degree?
Please indicate which of the following degree(s) you are currently pursuing or have completed:
☐ MS
☐MHA
☐ MPH
☐ MBA
☐ PhD
☐ Other: ____________________
Is your master’s program accredited through the Council on Education for Public Health (CEPH), Association to Advance Collegiate
Schools of Business (AACSB), and/or Commission on Accreditation of Healthcare Management Education (CAHME)?
☐ Yes ☐ No
Palomar Health Fellowship Application Form
Recommendations:
Please list the two individuals and their contact number that will be providing recommendation letters. One professional and one
academic reference are required.
Name
Title
Phone Number
Email Address
1.
2.
How did you hear about our Fellowship Program? (Please indicate all that apply):
☐ American College of Health Care Executives Website
☐ Graduate School/Career Center ☐ Palomar Health Website
☐ Word of Mouth ☐ Other: __________________________
Statement of Intent (2 paged, double-spaced, 11-pt font):
In your statement, please discuss: 1) your decision to pursue an administrative fellowship 2) why you are interested in Palomar
Health 3) the specific skills you would bring to the fellowship 4) a description of your future career goals within healthcare.
Application Materials:
All items below should be received in one envelope by September 25, 2015.
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☐
☐
☐
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Application Form
Current Resume
Statement of Intent
Official graduate school transcript
2 signed and sealed letters of recommendation (1 professional, 1 academic)