MEDICAL MICROBIOLOGY FELLOWSHIP
APPLICATION
Duke University Medical Center
Photograph optional
Academic Year ________________
(Please print or type)
Full Name ________________________________________________________________________________
Present Address ____________________________________________________________________________
City_______________
State______________
Zip________________
Country_____________________
Telephone ________________________________________________________________________________
Email Address ___________________________________
Birthdate _________
Citizenship___________________________
Visa Status (if applicable)_____________________________
Marital Status________________________
Permanent Address (name of person through whom you can always be contacted)
_________________________________________________________________________________________
City____________________ State_____________ Zip________ Country________________________
Premedical College__________________________
Advanced Work____________________________
Medical School_____________________________
USMLE Results
Step I:
Date___________________
Step II:
Date___________________
Step III:
Date___________________
Dates___________________
Dates___________________
Dates___________________
Degree____________
Degree____________
Degree____________
Numeric Score/% _______________
Numeric Score/% _______________
Numeric Score/% _______________
Foreign Medical Graduates must submit a copy of their valid ECFMG certificate.
Persons from whom letters of recommendation have been requested:
1)___________________________________________________________________________
2)___________________________________________________________________________
3)___________________________________________________________________________
Date _____________________ Signature _______________________________________________________________
Return this completed application, a copy of your curriculum vitae, and a one-page personal statement to:
Barbara D. Alexander, MD, MHS
Clinical Microbiology Laboratory, Box 3879
Duke University Medical Center, Durham, NC 27710