ࡱ > q bjbjt+t+ V~ A A x [ ] $ P . $ R " , ( " " " " " " " $ #$ & " " " " K ! " > t wLh : " UCLA NEPHROLOGY FELLOWSHIP PROGRAM
Application Form
YEAR:
Anticipated Starting Date in Program
Instructions: Please type or print clearly. Attach additional sheets if more space is needed.
IDENTIFYING INFORMATION
Last Name First Name Initial Social Security Number
Birth Date Birth Place Citizenship Vista Status Date Entered U.S. Country of Residence
Home Address City State Zip Home Telephone
Present Position Name of Institution
Institution Address City State Zip Office Telephone
Research Interest Email Address
PREMEDICAL EDUCATION
College or University Degree
Address City State Zip Date of Graduation
College or University Degree
Address City State Zip Date of Graduation
MEDICAL EDUCATION
Medical School Location Dates Attended Date of Graduation
CERTIFICATIONS
ECFMG # FMGEMS Date of Exam FLEX Date of Exam
Specialty Board Date
Specialty Board Date
POST MD TRAINING
PGY-1 to
Year Year Institution Location Type
PGY-2 to
Year Year Institution Location Type
PGY-3 to
Year Year Institution Location Type
PGY-4 to
Year Year Institution Location Type
PGY-5 to
Year Year Institution Location Type
Other to
Year Year Institution Location Type
LICENSURE
CA
State License Number Expiration Date
State License Number Dates of Licensure
State License Number Dates of Licensure
DEA Certificate Number Expiration Date
WORK EXPERIENCE
Please list relevant laboratory, research, or teaching assistant positions held. (You may include relevant voluntary experience)
Position TitleInstitutionDates EmployedPROFESSIONAL ORGANIZATIONS
Please list memberships in professional organizations and societies.
Name of Organization/SocietyMembership DatesPUBLICATIONS
Attach a sheet listing all publications, including abstracts, articles, monographs. You may attach a curriculum vitae and a personal statement regarding your interest in nephrology and future plans, if you wish.
REFERENCES
Please list the names and location of three references to whom you are going to send Confidential Reference Reports for completion. The first reference should be the program Director of your present or most recent clinical training program.
(1)Name:Title:Institution:(2)Name:Title:Institution:(3)Name:Title:Institution:SIGNATURE
X
APPLICANT DATE
COMPLETE YOUR APPLICATION
By sending all application materials to: Fellowship Program Coordinator, UCLA Nephrology Fellowship Program, 10833 Le Conte Avenue, 7-155 Factor Bldg., Los Angeles, CA 90095-1689; Direct any questions to: (310) 206-6741.
PERSONAL STATEMENT
(Please explain in detail: 1) why you have chosen to go into Nephrology; 2) why you wish to obtain a Ph.D.; & 3) your future goals relating to patient care and original research)
UCLA NEPHROLOGY FELLOWSHIP PROGRAM
TO THE APPLICANT
This section to be completed by the applicant before presenting to the reference.Applicants Name:Applicants Address:Applicants Telephone Number:
TO THE REFERENCE
The above-named applicant has applied for appointment to the UCLA Nephrology Fellowship and has named you as one of several references. We ask your cooperation in responding promptly. All replies will be held in strict confidence. Please note that the completed form is NOT to be returned to the applicant, but to the address below.
Please indicate below the period of time you have known the applicant and in what capacity.
Period of Time Known Capacity
Please mail completed form to:
Fellowship Program Coordinator
UCLA Nephrology Fellowship Program
David Geffen School of Medicine at UCLA
10833 Le Conte Avenue, 7-155 Factor Bldg.
Los Angeles, CA 90095-1689
Please contact the Fellowship Coordinator with any questions or concerns at (310) 206-6741.
SECTION I
Please rate the applicant by circling the appropriate number which most nearly represents your opinion of the applicant in comparison with a REPRESENTATIVE group of individuals you have known who have had approximately the same training and experience.
CharacteristicUnable to JudgePoor
Lowest 25%Fair
26-75%Excellent
76-90%Outstanding
Highest 10%Overall preparation for the Fellowship01234Industry/Perseverance01234Motivation01234Initiative01234Ability to meet deadlines01234Maturity01234Clinical Ability01234Interpersonal facility with peers01234Interpersonal facility with patients01234Demonstrated skill at research01234Potential skill at research01234Integrity01234Judgement/critical sense01234Intellectual ability01234Demonstrated originality01234Potential originality01234Leadership capacity01234Demonstrated productivity01234Potential productivity01234Ability to communicate (written)01234Ability to communicate (spoken)01234Commitment to Nephrology01234Commitment to Academic Medicine01234Overall Evaluation01234
SECTION II
Please elaborate on the applicants performance on the basis of which you arrived at your assessment in Section I. If possible, please cite from specific illustration of the applicants performance. You may attach a letter if you wish.
SIGNATURE
X
SIGNATURE OF REFERENCE DATE
PRINT NAME OF REFERENCE
TITLE OF REFERENCE
INSTITUTION
TELEPHONE NUMBER
Page PAGE 3 of 3
CONFIDENTIAL REFERENCE REPORT
Revised 4/02 Page PAGE 3 of 3
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