THE UNIVERSITY OF CHICAGO
DEPARTMENT OF PEDIATRICS
NEONATAL/PERINATAL MEDICINE
5841 S. MARYLAND AVENUE, MC 1051
CHICAGO, IL 60637
APPLICATION FOR NEONATAL/PERINATAL MEDICINE FELLOWSHIP
For Training Period: July 1, 200__ to June 30, 200__
Indicate the Subspecialty Area for which you are applying:
Specialty Training Choice (if applicable)
Specialty Training Choice (if applicable)
Specialty Training Choice (if applicable)
APPLICANT INFORMATION
Last Name
Street Address
City
Home Phone
Pager
State
First Name
M.I.
Country
Zip Code
Business Phone
Email Address
Date of Birth
Social Security No.
Cell Phone
Place of Birth
CITIZENSHIP
Citizenship (please check one)
U.S. Citizen
Permanent Resident
If not a citizen or permanent resident, please give visa status:
EDUCATION
Undergraduate
Medical School
Honors and Awards
Degree Upon Completion
Relative Class Rank
Date of Graduation
Date of Graduation
Internship
Inclusive Dates
Residency
Inclusive Dates
USMLE Scores
Part I
ECFMG Certificate No.
Part II
(MM / YY)
(MM / DD / YY)
(MM / YY-MM / YY)
(MM / YY-MM / YY)
Part III
ECFMG Issue Date:
Please provide a hard copy of the USMLE Scores and your ECFMG Certificate.
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THE UNIVERSITY OF CHICAGO
DEPARTMENT OF PEDIATRICS
NEONATAL/PERINATAL MEDICINE
5841 S. MARYLAND AVENUE, MC 1051
CHICAGO, IL 60637
Application - Page Two
EXPERIENCE
Hospital and Research Practical Experience (use additional sheet if necessary):
NOTE: You may complete and submit your application electronically. However, before your application
will be considered we must have the following:
1) Completed and signed hard copy of the application (please do not leave any items blank)
2) Curriculum Vitae
3) Personal Statement that delineates your career plans and gives us a brief biography
4) Hard copies of your USMLE Scores
5) A copy of your ECFMG certificate if you are a foreign medical graduate
6) Three letters of recommendation addressed to Lee Kwang-sun MD, Director, Neonatal/Perinatal
Fellowship Program
Please send completed application to:
Signature of Applicant
Maria Corpuz
University of Chicago
Department of Pediatrics
5841 S. Maryland Ave., MC 1051
Chicago, IL 60637-1470
Telephone: 773-702-3056
Fax: 773-702-0764
Email: mcorpuz@peds.bsd.uchicago.edu
Date
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