THE UNIVERSITY OF CHICAGODBpanruBNT oF MBoIcTNBSBcuoN op ENnocRINoLoGY. DIeeBrBs.5841 S. MARyr-ANl AvprlruB.MC 1027Curceco. IL 60637
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APPLICATION FORFor Training Period:
HYPERTENSION FELLOWSHIPJuly 1, 20-to June 30, 20-
APPLICANT INFORMATIONLast Name First Name M. I , -
-z lp uooe
Street AddressCity State Country
Home PhonePager
Date of Birth
Business PhoneEmail Address
Cell Phone
Place of BirthSocial Security No.
CITIZENSHIP
Citizenship (please check one) =
If not a citizen or permanent resident,
U.S. Cit izenPermanent Resident
please give visa status:
EDUCATIONUndergraduateMedical School
Date of Graduat ionDate of Graduat ion
Honors and AwardsDegree Upon CompletionRelative Class RankInternship Inclusive Dates
Inc lus ive Dates
Part IIIECFMG Issue Date:
ResidencyBoard Eligible or Board CertifiedUSMLE ScoresPart I Part IIECFMG Certificate No
Please provide a hard copy of the USMLE Scores and your ECFMG Certificate
THE UNIVERSITY OF CHICAGO HOSPITALS AND CLINICSDEPARTMENT/SECTION NAME5841 S. Mann eNl AvBltuB, MC _Curceco. IL 60637
Application - Page Two
EXPERIENCEHospital and Research Practical Experience (use additional sheet if necessary):
NOTE: You may complete and submit your application electronically. However. before your aoplicationwill be considered we must have the following:1) Completed and signed hard copy of the application (please do not leave any items blank)D Curriculum Vitae3) Personal Statement that delineates your career plans and gives us a brief biographyD Hard copies of your USMLE Scores5) A copy of your ECFMG certificate if you are a foreign medical graduate6) Three letters of recommendation addressed to George Bakris, MD, Director, Hypertension Fellowship
PIease send completed application to:
George Bakris, MDUniversity of ChicagoDepartment of MedicineSection of Endocrinology, Diabetes & Metabolism5841 S, Maryland Ave., MC1027Chicago, IL 60637-7470Telephone: 773-702-7936Fax: 773-834-0486Email: [email protected]
2
Signature of Applicant Date
