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APPLICATION FOR

 FELLOWSHIP TRAINING

                      IN

         CARDIOLOGY

UNIVERSITY OF COLORADO

HEALTH SCIEN...
Name: _________________________________________________           Soc. Sec. #: ____________________

Present Home Address:...
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Cardiology Fellowship Application

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Cardiology Fellowship Application

  1. 1. APPLICATION FOR FELLOWSHIP TRAINING IN CARDIOLOGY UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER Edward P. Havranek, M.D. Associate Professor of Medicine Director, Fellowship Training Program Division of Cardiology, B130 University of Colorado Health Sciences Center 4200 East Ninth Avenue Denver, CO 80262 1
  2. 2. Name: _________________________________________________ Soc. Sec. #: ____________________ Present Home Address: ___________________________________ Home Telephone No.:____________ _________________________________________________________________________________________ _ Place of Birth: _____________________________ Date of Birth: ____________ U.S. Citizen?_____________ If not a U.S. Citizen, please describe status: ______________________________________________________ _________________________________________________________________________________________ _ Condition of Health: ________________________________________________________________________ _________________________________________________________________________________________ _ Marital Status:______________________ Children: _______________________________________ Education: (Schools, dates, degrees) College: _______________________________________________ Major: ________________________ Medical School: ____________________________________________________________________________ Present Position: ___________________________________________________________________________ Present Work Address: _________________________________ Work Telephone No.: __________________ Internship and Residency: ____________________________________________________________________ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ Special Training (Graduate School or Fellowships): ________________________________________________ _________________________________________________________________________________________ _ 2
  3. 3. _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ Licensure to Practice Medicine in the Following States: _____________________________________________ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ Present Plans (e.g., training you would like to receive): _____________________________________________ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ Research Experience and Any Publication(s): _____________________________________________________ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ 3
  4. 4. _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ Future Plans: ______________________________________________________________________________ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ _________________________________________________________________________________________ _ References (Please request that they write directly to us): 1. ______________________________________________________________________________________ _ _________________________________________________________________________________________ _ 2. ______________________________________________________________________________________ _ 4
  5. 5. 3. ______________________________________________________________________________________ _ _________________________________________________________________________________________ _ Please enclose a letter from your medical school Dean stating your approximate class rank and/or follow with a photocopy of your medical college transcript as well as a recent photograph. PHOTO 5

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