Bongolo Hospital
Ophthalmology Residency Program
B.P. 13.021
Libreville, Gabon
Wendyhofman12@gmail.com
Ophthalmology Residency Application
Please note: If you are over 35 years old, your chances of being accepted into the ophthalmology program will be
considerably less than for younger candidates, but you may complete the process of applying if you wish. If you are
over 40 years old, we regret that we will not be able to process your application.
Applicants must also be medical doctors, having completed medical school. Prior to beginning ophthalmology
residency, applicants must also complete one year of continued supervised medical education (internship) in one of
the following areas: internal medicine, general surgery, pediatrics, or family medicine.
The residency program is of three years’ duration, and married applicants must not be separated from spouses for
longer than one year. Applicants must also be conversant in both oral and written French and English.
Instructions: Move from blank to blank using the tab key. If there is a box, type in “x” to signify the correct answer. If there is a rectangle, then type your
answer in that rectangle.
Section I: General Information
Surname
Date of Birth:
First Name
(Applicants must be age 35 or younger)
Other Names
Name you go by:
Gender/Sex
Male
Nationality:
Spouse’s Names:
Spouse’s Date of Birth:
Date of Marriage:
Female
List the names, date of birth, and ages of your own children under the age of 18. If the children were not born to you
or your spouse, please check if legally adopted.
1.
Date of Birth
Age
Adopted
2.
Date of Birth
Age
Adopted
3.
Date of Birth
Age
Adopted
4.
Date of Birth
Age
Adopted
5.
Date of Birth
Age
Adopted
Your Current Mailing Address:
One or several phone numbers where we can reach you:
Cell Phone Number (include country code)
Your current e-mail address:
July 1, 2013
Please check here to certify that you speak, read, and write at least conversant French:
This is a program requirement.
Please check here to certify that you speak, read, and write at least conversant English:
This is a program requirement.
Section II: Academic History
Please list, in order, the schools you have attended:
Dates
School Name and Address
1. From
to
2. From
to
3. From
to
4. From
to
5. From
to
6. From
to
7. From
to
Diploma Received
Describe any medical training you received after graduating from medical school. For each entry, describe the didactic
program and the level of supervision you received from instructors during this training:
Dates
1. From
Hospital Name and Address
Certification
to
Didactic/Supervisory Description:
2. From
to
Didactic/Supervisory Description:
3. From
to
Didactic/Supervisory Description:
4. From
to
Didactic/Supervisory Description:
List the places you have worked since graduation from medical school:
Dates (give both month & year mm/yy) Name and Address
1.
to
2.
to
3.
to
4.
to
Position Held
Do you have any obligations to any organization (hospital, a government, church, military, mission agency, etc.) that
you are required to complete either currently or at some date in the future?
Yes
No. If you answered yes,
please provide a description of any obligation.
.
July 1, 2013
Please answer the following questions. Each response should be 200 words or less:
1. Why did you choose to go into medicine as a career?
2. Why do you want to become an ophthalmologist?
3. What attributes and abilities do you have that you believe will help you in pursuing ophthalmology as a career?
4. How are you prepared to handle the rigors of three years of ophthalmology residency training?
5. What do you want to do after you finish ophthalmology training?
Section III: Finances
Please list your current salary per month:
Currency:
Amount:
During our residency program, each resident receives a salary, housing, and internet access for the three years.
These expenses must be covered by some institution or individual. The average total cost per year for the
residency is approximately:
 For a single person: $7570 US
 Married without children: $9690 US
 Married with children: $11820 US
Please select one of the following 3 options:
1. I have asked a hospital/church/denomination/sending institution to pay these expenses for me. After
residency graduation, I will commit to working for this institution for at least 5 years.
 Their response when I asked them for financial support was:
(Answer only “Yes” or “No”)
 The name of the institution is:
 The institution’s mailing address is:
 The name of the person responsible to authorize this payment is:
 The email address of the person responsible to authorize this payment is:
2. I would like to apply for Bongolo Hospital to pay these expenses for me. After graduation, I will commit to
working for Bongolo Hospital for at least 5 years at a similar salary.
3. I will pay for these expenses myself, out of personal savings.
Note: These amounts above are rough estimates and may be modified. In addition, international travel to and from
Bongolo Hospital will be paid by the resident personally and is not included here.
Section IV: Spiritual
SPIRITUAL DECLARATION - THIS SECTION GIVING YOUR TESTIMONY IS VERY IMPORTANT TO YOUR ACCEPTANCE!
Below in the highlighted space, write a 1,000-word testimony of how you came to faith in Jesus Christ. Explain how this
has changed your life from that moment until the present. Please take your time and do it well. It should be typed here
below and detailed enough to take up at least three full pages. It should include clear answers to the following
questions:
July 1, 2013
1.
2.
3.
4.
5.
6.
7.
What was your life like before you met Jesus? (Please include relationships with members of the opposite sex
that produced children or marriages that ended in divorce.)
How did you come to realize that you needed Jesus?
How did you then commit your life to Jesus?
What does it mean to you to “repent of your sin”?
What difference has your commitment to Jesus made in your lifestyle?
How do you see your medical work as a ministry?
What has God taught you from:
(a) Failure?
(b) Success?
(c) Lack of money?
(d) Pain, illness, suffering, sorrow or depression?
(e) Disappointment?
(f) Other life trials?
Write your 3-page response starting here:
What is the name and location of the church that you currently attend?
Provide your pastor’s name, mailing address, e-mail address, & telephone number:
Name:
E-mail:
Mailing address:
Telephone:
Section V: References
Provide the names and e-mail addresses and/or telephone numbers of two people that we can contact who can tell us
something about you and state their relationship to you (supervisor, deacon, friend, professional colleague, etc.):
Name
Relationship
E-mail Address
Phone Number
1.
2.
Section VI: YOUR ACCEPTANCE OF THE FOLLOWING OPHTHALMOLOGY RESIDENCY POLICIES
1.
2.
3.
4.
5.
I fully understand that by signing this application, I agree to the following policies of the Bongolo Hospital
Ophthalmology Training Program:
Each year residents must prepare and give frequent formal oral presentations or written case reports.
Residents will be required to first-assist or perform a minimum of 150 operations a year and will fill out and turn in to
their program director a yearly record of operations.
Residents will take exams throughout the year, as well as a comprehensive examination each year. If a resident does
not pass an annual exam, the program director is not obliged to advance him to the next level of training. If a
program director does not believe that a resident’s effort or skill justifies his repeating the year, or if a program
director finds that a resident is insubordinate or irresponsible, he is under no obligation to keep the resident in the
training program.
A resident will receive Bongolo Hospital Ophthalmology certification only if he or she completes all of the
requirements during all three years of the training program. If he drops out after completing only part of the
ophthalmology training program or does not pass his final exams, his program director will give him a certificate of
training from Bongolo Hospital stating only that he completed a certain number of years of formal surgical training.
If the resident is sponsored by a sending institution or by Bongolo Hospital, he must agree to accept the same level of
reimbursement as received by the other residents at that same level of training at Bongolo Hospital.
July 1, 2013
6. Residents are not permitted to receive direct payment for their services from patients.
7. Residents understand and agree to comply with the Bongolo Hospital Ophthalmology Residency policy on spousal
separation: You cannot live apart from your spouse for a period of time exceeding one year during the 3 year
program.
8. Failure to provide accurate and complete information or failing to disclose pertinent information may lead to
dismissal from the program or a failure to be accepted.
9. Each Ophthalmology resident must accept in full the following Bongolo Ophthalmology Residency statement of belief:
OPHTHALMOLOGY RESIDENCY STATEMENT OF BELIEF

We believe that the Bible, in its entirety, is the only inspired, inerrant Word of God.

We believe that there is one God eternally existent in three persons: the Father, the Son and the Holy Spirit.

We believe that Jesus Christ is God the Son, born of a virgin, fully God and fully Man, who willingly died on a
cross for the sins of Man and rose from the dead to sit at the right hand of the Father.

We believe that all men are by their very nature sinful and that the forgiveness of sin and the gift of eternal
life come only through repentance and faith in Jesus Christ.

We believe in the ministry of the Holy Spirit who indwells those who are born again by the Spirit of God, and
enables believers to live a godly life.

We believe in the personal return of Jesus Christ to reign in power and glory on the earth. He will judge the
saved and the lost – the saved will receive eternal life and the lost will receive everlasting punishment.

We believe in the unity of all believers who love, worship and obey Jesus Christ as the Son of God.

We believe that it is the duty of all who love and obey Jesus Christ to proclaim his gospel to their neighbors
and to the world, and to respond with compassion to the suffering around them in the ways that Jesus did,
regardless of race, religion, nationality, or social status.
Please accept my application to become a resident in the Bongolo Hospital Ophthalmology Training Program. I hereby
certify that I am in good health, am HIV-negative, and have excellent vision in each eye. I agree to all the terms and
conditions stated herein and hereby certify that all information I have provided is correct to the best of my
knowledge and belief.
Your Printed Name:
Date Application completed:
ADDITIONAL REQUIREMENTS
Your application must include the following to be complete:
 A copy of your birth certificate (if you have one, if you do not, provide a copy of your government issued photo ID)
 A copy of your marriage license (if married)
 A copy your medical diploma
 A copy of your medical license (Ordre des Medecins)
 A completed recommendation form from your church pastor or board
 A completed recommendation form from a Christian medical colleague
 A color photograph (scanned, attached to an e-mail or mailed) of yourself
Kindly Note: You are responsible to see that all these forms and documents are submitted.
You are responsible for documents not in English to have an authorized translation.
Once the above information is completed, if you are selected to continue, you will be notified by e-mail and you will
be asked to complete the following items at that time:
 An essay on a medical topic that we choose
 A telephone interview
July 1, 2013
Please E-mail this application and scans of all the requested documents to: wendyhofman12@gmail.com
Alternately, you may use this mailing address:
Hôpital de Bongolo
Dr. Wendy Hofman
B.P. 13.021
Libreville, Gabon
For Applicant’s Use Only
Please keep a list of dates as you e-mail documents to the Ophthalmology Residency. The deadline for
having all of your information received by the Ophthalmology Residency is February 1. You are strongly
encouraged not to wait until the last minute to get this information to us as it often takes several months
for you to obtain it!
We also ask that you make an effort to turn as many documents as possible in on the same date.
Send the following list to wendyhofman12@gmail.com when complete. This will assist both you and the
Ophthalmology Residency in making sure that all documents are received by the appropriate deadline.
Document
Date e-mailed to PAACS
Application
Birth Certificate
Marriage License
Medical License or Ordre des Medecins
Medical Diploma
Recommendation Form from Pastor
Recommendation Form from Colleague
Color Photo
Essay
Important Dates :
February 1 : Application and all documents must be received by Ophthalmology
Residency
March 15 : Candidates will be chosen and notified (no candidate will be notified
prior to that date)
July 1 : Chosen candidates must report to their assigned program
July 1, 2013