THE HOSPITAL FOR SPECIAL SURGERY-CORNELL UNIVERSITY MEDICAL COLLEGE

535 East 70^th Street

New York, New York 10021

PEDIATRIC RHEUMATIC DISEASE FELLOWSHIP APPLICATION

Note: Please type or print all entries

Date: __________________________

Name: ________________________________________________________________________

                        ^{Last
Name                                                                  First
Name                                                 Middle
Name}

Permanent Address: _____________________________________________________________

^{No. and Street City State Zip Code Tel.#}

Present Address: ________________________________________________________________

^{No. and Street City State Zip Code Tel.#}_{Until:
_______________________________________}

Citizenship: USA ________________ Other Nationality: ________________________

SSN ________________ ECFMG # _____________ Type of Visa:____

Education: Please indicate institutions. Inclusive dates of attendance and degrees received; a Curriculum Vitae is desired.

College: ____________________________________ Degree & Year: __________________

Address: ______________________________________________________________________

Medical School: ______________________________ Degree & Year: __________________

Address: ______________________________________________________________________

Internship: ____________________________________________________________________

^{Name of Hospital Address}

________________________ ________________________________________

^{Type From To}

Residency: ____________________________________________________________________

^{Name of Hospital Address}

________________________ ________________________________________

^{Type From To}

Licensed in state of: _______________________________________ Year ________________

N.Y. State License # __________ Year _______ N.Y. State Temp. Cert. # _________________

Fellowships: ___________________________________________________________________

^{Name of Hospital Address}

______________________ ________________________________________

^{Type From To}

___________________________________________________________________

^{Name of Hospital Address}

________________________ ________________________________________

^{Type From To}

Investigative work in Medicine: List titles and publication dates of papers.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Previous experience in fields other than Medicine: (Business, Industry, Teaching, et cetera). Field and inclusive dates should be indicated.

PERSONAL HISTORY:

Date and place of birth: __________________________________________________________

Name and address of nearest relative: ______________________________________________ ______________________________________________

Marital Status: _____________ Spouse’s Name _______________________ # of Children ____

References: Please list names and addresses of three persons who have definite knowledge of the applicants qualifications and fitness for the position for which application is made. At least two should be physicians under whom the applicant has served.

____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________

Date: _________________ Signature: ________________________________________________

This application and all related communications should be addressed to: