Application for Osteopathic Residency/Fellowship Program
I wish to apply and interview for the: Anesthesia Obstetrics/Gynecology Orthopedic Surgery Surgery Family Practice Internal Medicine
Other:
Application Date: Starting Year:
Name:
Social Security Number: Phone Number:
AOA Number: U.S. Citizen: Yes No
Licensure: State: Year Number State: Year Number (if applicable)
Present Address:
Address 1: Address 2: City: State: Zip:
Email:
Notification Phone: (if different from above phone number)
Premedical:
(1) College: Degree: Completed: Address 1: Address 2: City: State: Zip:
(2) College: Degree: Completed: Address 1: Address 2: City: State: Zip:
Osteopathic:
College: Degree: Completed: Address 1: Address 2: City: State: Zip: Phone:
Internship:
Hospital: Expected to Complete: Address 1: Address 2: City: State: Zip: Phone:
Other Post-Graduate Training and Professional Memberships:
(1) (2) (3)
Do you have any Physical, Mental, or Substance Abuse Problems which, to you knowledge, could interfere with your ability to perform the essential functions of the job and/or complete the rigorous requirements of Residency Training Program? Yes No
If Yes, Please Describe the Problem, Related Therapy, etc. (Send Documentation as Necessary):
Do You Have an Armed Services Commitment? Yes No
If Yes, Please Describe:
Comments:
Please Send a Letter Describing:
(a) Why have you applied to the IRMC/MSU Program? (b) Hobbies, Activities, Interest and Volunteer Experience. (c) Professional and Educational Goals Following Residency. (d) Research Experience and Publications (e) Personal Statement
Application Will Be Considered Upon Receipt of the Following:
(a) Letters of recommendations from Physicians who are familiar with your work. (b) Transcripts (c) National Board Scores (Photocopy) (d) Dean's letter from your Medical School (e) DME Letter from your Internship Hospital (f) Copy of Curriculum Vitae (g) Undergraduate Diploma (h) Medical School Diploma (i) Current Licensure (j) ACLS Certificate
I understand that my training is in accordance with the American Osteopathic Association's policies and procedures as stated by the Committee on Postdoctoral Training. I recognize my responsibility to cooperate with and assist the Professional Staff and Hospital Administration in matters that pertain to the maintenance and development of my profession and Ingham Regional Medical Center.
If you agree to the above, initial here
