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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