Procedural Dermatology Fellowship Training Application
UT SOUTHWESTERN MEDICAL CENTER AT DALLAS
Department of Dermatology - Division of Dermatology Surgery
If you would like to submit an application for the 2008-09 program, please use the form below. Application must be received by November 3, 2008.
Please return completed copy of application to:
The University of Texas Southwestern Medical Center at Dallas
Dermatology Surgery Fellowship Program
5323 Harry Hines Blvd.
Dallas, TX 75390-9192
Telephone Inquiries: (214) 645-8948 - Lidia Ortiz ~ Fellowship Coordinator
E-mail Inquiries: stan.taylor@utsouthwestern.edu
Department Home Page: http://www.utsouthwestern.edu/patientcare/medicalservices/dermatology.html
The following documents are required as part of your application:
- Transcript of medical school grades
- Three letters of recommendation from faculty members or physicians who have known of your clinical ability
- ECFMG Certificate or status
- SF Match ID# or email to lidia.ortiz@utsouthwestern.edu once this is available to you.
- Curriculum vitae, bibliography and photo
- Photocopy of official documentation of scores and percentiles from USMLE Part I and II
- Responses to questions regarding application (in place of personal statement) (form enclosed)
*Your application can not be processed until all required documents are received by our office*
APPLICATION:
Fellowship in: Procedural Dermatology
Fellowship Dates: July 1, 2008-June 30, 2008
Name: Date of Birth:
Present Address: Telephone:
_____________________________ Sex: Male _____ Female ____
(CITY) (STATE) (ZIP)
Military Status: Country of Citizenship: ________
PRE-MEDICAL EDUCATION
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Name of Institution
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City and State
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From
Month/Year
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To
Month/Year
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Degree/Major
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| High School __________________________ |
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| College _______________________________ |
____________ |
________ |
________ |
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| Graduate School ________________________ |
____________ |
________ |
________ |
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MEDICAL EDUCATION
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Name of Institution
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City and State
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From
Month/Year
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Month/Year
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Degree/Major
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| ___________________________________ |
______________ |
__________ |
_________ |
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| ___________________________________ |
______________ |
__________ |
_________ |
______________ |
INTERNSHIP AND/OR RESIDENCY TRAINING
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Name of Institution
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City and State
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From
Month/year
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To
Month/Year
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Degree/Major
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| ___________________________________ |
_____________ |
_________ |
_________ |
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| ___________________________________ |
_____________ |
_________ |
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| ___________________________________ |
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_________ |
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USMLE SCORES AND PERCENTILES
Part I: ______ Part II: ______ Part III: _______
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Foriegn Graduates or Non-Citizens:
Do you have ECFMG certification? __________ (Send copy of certificate)
Have you passed the equivalent of the USMLE? ________ (Send copy of official documentation of scores and percentiles)
Visa status: _______________________ (Send copy of visa)
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LIST THOSE WRITING THE 3 LETTERS OF RECOMMENDATION (name, address, position):
QUESTIONS REGARDING APPLICATION
Hand-written, typed, or printed responses are acceptable, but must be limited to the spaces provided.
1. Why do you want to be a dermatologic surgeon?
2. Applicants' interest in applying at UT Southwestern may be routine or special. What, if any, has particularly attracted you to our fellowship training program?
3. What strengths would you bring to a fellowship program?
4. What do you plan to do after your fellowship? Why?
5. How do you see yourself 10 years from now?
6. Is there any other information you wish to communicate about yourself?
_______________________________________ ______________________
Signature Date
**With few exceptions, you are entitled on your request to be informed about the information U.T. Southwestern Medical Center at Dallas collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have U.T. Southwestern Medical Center at Dallas correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in The University of Texas System Business Procedures Memorandum 32. The information that U.T. Southwestern Medical Center at Dallas collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.
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AFFILIATED HOSPITALS
Children's Medical Center
Dallas Veterans Administration Hospital
Parkland Health and Hospital System
St. Paul Medical Center
Zale-Lipshy University Hospital
