PEDIATRIC CARDIOLOGY FELLOWSHIP PROGRAM
Application for 2011-2012 Academic Year
University of Washington Affiliated Hospitals
Seattle, Washington
Date:
Name:
Address:
Work Phone:
Home Phone:
Cell Phone:
Pager:
Email:
Social Security Number:
Sex:
M
F
Date of Birth:
Citizenship:
If you graduated from a foreign medical school, do you have an ECFMG certificate:
YES
NO
ECFMG Number:
Type of Visa:
Visa Number:
PRE-MEDICAL EDUCATION
College and
location
Major area of study
Dates of Attendance
Degree and Date
Awarded
MEDICAL EDUCATION
INTERNSHIPS, RESIDENCIES, AND FELLOWSHIPS
Name of Hospital
Location
Specialty
Dates Begun and
Completed
The University of Washington provides equal opportunity in education on the basis of race, color, national origin, and
sex in accordance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments and Sections
799A and 855 of the Public Health Service Act.
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Pediatric Cardiology Fellowship Application Page
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References

One letter from the director of your residency program.

Two letters from faculty or professional staff of your medical school or hospitals where you
have worked in the past five years.
Additional recommendations may be added. List names of all references below:
Name and Title
Type of Contact
Institution, City, State
Membership in Professional Societies
Are you licensed to practice medicine?
In which state(s)?
Y
_____________________________________
Signature
N
_____________________________
Date
Please include with this application the following:

3 Letters of Recommendation

Curriculum Vitae

Personal Statement

Passport style photo
Copyright 2005 © Pediatric Cardiology. All rights reserved.
The University of Washington provides equal opportunity in education on the basis of race, color, national origin, and sex in
accordance with Title VI of the Civil Rights Act of 1964 and Title IX of the Education Amendments and Sections 799A and 855
of the Public Health Service Act.
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