UNIVERSITY OF SOUTH FLORIDA



H. Lee Moffitt Cancer Center & Research Institute

University of South Florida Departments of Dermatopathology, Pathology and Cell Biology

DERMATOPATHOLOGY FELLOWSHIP PROGRAM

DIRECTIONS

1) The attached application should be filled out completely and returned promptly.

2) Request the Registrar of your medical school to forward a transcript of your grades. If you have attended more than one medical school, each school must send an original transcript. If you received a degree, it should show on the transcript.

3) A recent photograph, lightweight, unmounted, 2” x 3”, must accompany this application. (Attached to last page of application.)

4) Applicants for this training program are selected on the basis of scholarly achievements, character, personality, moral integrity and stability.

5) At least 3 professional references must be sent directly to the return address indicated. One of these must be a letter from the Director of your Residency Program.

6) Prompt submission of the completed application and ALL required documents are the responsibility of the applicant. NO application will be given consideration until ALL of the required documents are received.

7) Programs, activities and facilities of the University of South Florida are available to all on a non-discrimination basis, without regard to race, color, creed, religion, sex, age or national origin. The University of South Florida is an Affirmative Action – Equal Opportunity Employer.

8) PLEASE TYPE APPLICATION.

(This form cannot be completed on line)

You may be invited to come for a personal interview. An invitation to appear for an interview means only that your initial evaluation is sufficiently high enough to warrant further consideration. Individuals not accepted for fellowship training will be notified.

Programs, activities and facilities of the University of South Florida are available to all on a non- discrimination basis, without regard to race, color, creed, religion, sex, age or national origin. The University of South Florida is an Affirmative Action – Equal Opportunity Employer.

University of South Florida – Department of Pathology

12901 Bruce B. Downs Blvd. – MDC 11 - Tampa FL 33612

FELLOWSHIP APPLICATION

UNIVERSITY OF SOUTH FLORIDA

DERMATOPATHOLOGY

12901 BRUCE B. DOWNS BLVD., MDC 79

TAMPA, FLORIDA 33612

Year Applying for: _____________

PLEASE PRINT OR TYPE APPLICATION

PERSONAL DATA

Name:

_____________________________________________________________________________________

Last First Middle Maiden

Sex: M / F Birthdate: ____________________Social Security No: _________________________

Month/Day/Year

Citizen of: __________________________ Birthplace: ______________________________________

Present Address: _____________________________________________________________________

Street Address

____________________________________________________________________________________

City State/Country Zip

Telephone Number: ____________________________________

Area Code Number

Email Address: ________________________________________

EDUCATION

List below the medical school and residency program(s) you have attended and graduated from:

Name of School Location Dates To/From Degree/Date

_____________________________________________________________________________________

_____________________________________________________________________________________

Residency Program Address Contact Phone Number

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

PROFESSIONAL EXPERIENCES, LICENSES, ETC. (Attach extra sheet, if necessary)

Hospitals Nature of Work Dates To/From

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

If time has elapsed since leaving residency, give dates and what you have been doing.

_____________________________________________________________________________________

_____________________________________________________________________________________

List key biographical data, papers, publications, etc. that will strengthen your application and attach a current Curriculum Vitae.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

List any honors/awards you received during medical school or residency.

Medical License Number and State of issue: _______________________________________________

Military Service Status: ________________________________________________________________

Have you ever been convicted of a felony? YES / NO If yes, please explain:

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever been dropped from a college, professional school or training program? YES / NO

If yes, please explain: _________________________________________________________________

____________________________________________________________________________________

Race (required by H.E.W., Title VI of Civil Rights Act)

Black Am Caucasian Am Indian Puerto Rican Mex Am Spanish

Oriental Other Asian Other: ____________________________________________________

Are you in good health: YES / NO

Do you have, or have you had, any physical or mental illness or impairments? YES / NO

If so, please explain: __________________________________________________________________

EXTRACURRICULAR ACTIVITIES

DOCUMENTS REQUIRED

Your application will not be considered until ALL required documents are received.

• Original transcript of grades from medical school registrar

• Personal References (3) List Names & Address: (letters must be sent under separate cover)

List References (3):

_____________________________________________________________________________________

Name Phone (including area code)

________________________________________________________________________________________________________

Street City State/Country Zip

_____________________________________________________________________________________

Name Phone (including area code)

________________________________________________________________________________________________________

Street City State/Country Zip

_____________________________________________________________________________________

Name Phone (including area code)

________________________________________________________________________________________________________

Street City State/Country Zip

I certify that the information given in this application is accurate and complete to the best of my knowledge and understand that falsification of information will be sufficient grounds for refusal of admission for dismissal. If admitted to the University of South Florida College of Medicine Fellowship Program, I hereby agree to abide by the policies of the Board of Regents and the rules and regulations of the University of South Florida College of Medicine.

Signed: __________________________________________________ Date: _____________________

ADDRESS APPLICATION TO:

L. Frank Glass, M.D. PHOTO 2 x 3 (approximate)

USF Dermatopathology

12901 Bruce B Downs Blvd

MDC Box 79

Tampa FL 33612

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