THE HOSPITAL FOR SPECIAL SURGERY-CORNELL UNIVERSITY MEDICAL COLLEGE

535 East 70th 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.

  1. ____________________________________________________________________________________________________________________________________________________________
  2. ____________________________________________________________________________________________________________________________________________________________
  3. ____________________________________________________________________________________________________________________________________________________________

 

 

Date:    _________________     Signature: ________________________________________________

 

This application and all related communications should be addressed to:

 


Thomas J. A. Lehman, MD

Hospital. For Special Surgery

535 E. 70th Street

New York, NY 10021

 

It can be returned by Email to goldscout@aol.com

Or faxed to 212-606-1938 or sent by regular mail.