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2009 FELLOWSHIP IN PUBLIC PSYCHIATRY APPLICATION

1. Name: (First, Middle, Last)    

2. Home Address:    
    Home Phone:    
    Email:    

    Work Address:    
    Work Phone:    
    Email:    

3. Are you currently a member of the
    American Psychiatric Association?		     Yes   No
    If YES, (if known) please enter
    Membership number:		    

4. If NO, are you in the process of becoming
    an APA member?		     Yes    No

EDUCATIONAL BACKGROUND:

5. Pre-medical education
    (name/location of college, years attended, degree received, major):
Name    
Location    
Dates    
Degree    
Major    

6. Medical Education
    (name/location of medical schools, years attended, year MD/DO
    degree received):
Name    
Location    
Dates    
Degree    

7. Internship
     (indicate if internship was separate from or combined with first year
     of residency):
separate combined
Name    
Location    
Dates    

8. Residency Training:
Name    
Location    

9. PGY Level:
Current Level:    
Current Residency Year Began:    
PGY Level as of May 2011:    


10. Indicate any other medical training or experience:


11. Indicate area(s) of special interest in psychiatry:


12. List honors, awards, recognition (e.g. scholastic, career, public service):


13. List prior employment:


14(a). College public service and/or volunteer activities:


14(b). Medical School public service and/or volunteer activities:


14(c). Residency public service and/or volunteer activities:


15. Describe your primary extracurricular activities in a few sentences:


16. Briefly describe any research experience you have had (e.g., thesis):


17. List any published original works, giving dates and sources:


18. List any organizational memberships or affiliations:


19. What are your plans as a participant in the public service sector after completion of your current training?


20. Other personal attributes or experiences that you believe might distinguish you from other candidates:


ESSAY:



21. Write an essay, not to exceed two single-spaced pages, proposing how the fellowship would be utilized to enhance your present training and ultimately assist you in achieving your career goals.



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