Stanford University Medical Center
Department of Radiology, Neuroradiology Section
Application for Fellowship for 2017 - 2019
Positions to fill 4
300 Pasteur Drive, Room S-047
Stanford, CA 94305-5105
Telephone: (650) 723-7426
Fax: (650) 498-5374
Name:
Last
First
Middle
Work Address:
Hospital
Name, Department
Street, Suite, Division, Room Number
City
Work Phone:
(
State
)
Country
Fax: (
Zip
)
Home Address:
Street, P.O. Box, Apartment Number
City
Home Phone:
Pager:
(
(
State
)
)
Country
Zip
Fax: (
)
E-mail:__________________
Please indicate preference for correspondence:
Work [
]
Home [
]
Birth date:
Social Security #:
(last 4 digits)
Please include
Citizenship:
a 2 x 2 inch
Birth Place:
photograph
Med. license no.
Residency
Internship*
Date Graduated:
Medical School
Date Graduated:
*A one-year internship is required to be licensed in the State of California
Stanford University Medical Center
Department of Radiology, Neuroradiology Section
Application for Fellowship for 2017 - 2019
The application requires completion of the following, in addition to your CV, personal
statement and this completed application:
1.
California medical licensure is required to complete a fellowship. The California
State Medical Board at (916) 263-2499 may be contacted for questions about
licensure.
2.
Three letters of recommendation mailed to:
Huy M. Do, M.D.
Stanford University Medical Center
Department of Radiology, Neuroradiology
300 Pasteur Drive, Room S-047
Stanford, CA 94305-5105
Letters of Recommendation will be sent by:
Name
Institution