Godina Traveling Fellow Application
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Demographic Information:
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Name
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Street
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Apt
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City |
State |
Zip |
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Country
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Business Phone
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Business Fax |
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Home Phone |
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Home Fax |
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Email Address |
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Date of Birth |
mm/dd/yy: _____/______/______ |
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Education: |
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College |
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Medical School |
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Residency Training |
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Fellowship Training |
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Professional Experience: |
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Current Position |
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Prior Positions |
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References: (please provide at least 3 letters of recommendation from ASRM or WSRM members) |
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1. |
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2. |
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3. |
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* Please also include: a recent photograph, curriculum vitae and
a 1 page explanation why you should be selected as the Godina Travelling Fellow.
All Applications may be sent to the Central Office:
Due September 25
20 N. Michigan Ave, Suite 700
Chicago, IL 60602
Fax: 312-853-1646
Email: contact@microsurg.org