FELLOWSHIP APPLICATION DEPARTMENT OF ANESTHESIOLOGY MILTON S. HERSHEY MEDICAL CENTER FELLOWSHIP ADMISSIONS OFFICE THE PENNSYLVANIA STATE UNIVERSITY

Please print or type:

NAME:         

                Last, First,  Middle

Email address:          
 

DESIRED START DATE/TYPE OF FELLOWSHIP: 

PRESENT MAILING ADDRESS:

    PHONE:

Number                        Street               City                  State           Zip

PERMANENT MAILING ADDRESS (If different than above)
   PHONE:

Number           Street                City                  State           Zip

ARE YOU A CITIZEN OF THE U.S.?:  Yes No  If not, do you intend to become a citizen of the U.S.?  Yes No

*Our cardiothoracic anesthesiology fellowship program only accepts permanent residents and U.S. citizens.

If non U.S. citizen, what is your Visa status? Ending date:

TEST SCORES:

MEDICAL SCHOOL: 

Name  City/State        Type of Degree/Date 

LICENSURE:  Description #DateState

PLEASE SUBMIT THE FOLLOWING ALONG WITH YOUR COMPLETED APPLICATION:

CURRICULUM VITAE:  To include:  a) previous education, degrees and date obtained; b) previous graduate training;

c) work experience, including medical; d) research experience; e) extracurricular activities; f) honors; and g) publications

PERSONAL STATEMENT:  Please explain your choice of career, previous experience in anesthesia and career objectives.

(You are not required to name any group or activity which may reveal your race, religion, national origin or sex).

REFERENCES:  A letter from the Dean of your medical school should accompany a transcript of your medical school grades. 

Otherwise, the first reference should be the chairman of the department in which you currently work.  It is advisable for

you to request letters from faculty members with whom you have been closely associated. 

1.

            Name                           Position                         Address                                    Zip

2.

            Name                           Position                         Address                                    Zip

3.

            Name                           Position                         Address                                    Zip

Applicant should return this completed application form and above requested material to: 

        Choose fellowship desired:  Bonnie Smith - Cardiac and Critical Care Fellowships Joann Spangler - Regional Anesthesia Fellowships Janet Zeager - Pediatric Fellowships Connie Williard - Pain Fellowships Karen Bowman - Neuro/Anesthesia Fellowship      

                                                Penn State Milton S. Hershey Medical Center                                                                                                         

                                                Department of Anesthesiology   H187 (*use HU32 for Pain Fellowship)

                                                P.O. Box 850                  

Hershey, PA  17033

Today's Date     Signature ______________________________________

Step 1) Click Here to Print (print this application, sign, and mail along with the additional information requested above)

Step 2) click here to submit Fellowship Application form