Application for Fellowship in Glaucoma To begin _________________ WILLS EYE INSTITUTE AFFILIATED WITH JEFFERSON MEDICAL COLLEGE OF THOMAS JEFFERSON UNIVERSITY

Attach Photograph (2 x 2 inches)

Match #:  Date & Place of Birth:

Full Name (Print):

Present Address & Phone: Permanent Address & Phone:

Social Security Number: E-Mail Address: 

Type of Fellowship Desired: Cell Phone:

Dates of Appointment Preferred:

Premedical & Medical Education (Have transcripts forwarded from medical school):

Undergraduate School City & State Dates Attended Degree

Medical School City & State Dates Attended Degree

National Boards: Part I–Date _______ Score________ Part II-Date________ Score________ Part III–Date_______ Score________

Internship (give name of hospital, city and state, and dates):

Other Professional Experience (list institutions, titles held, and dates):

Previous Training in Ophthalmology:

Academic Honors, Scholarships, Fellowships, Publications:

Medical Licensure (list state, date, and license number):

(Unrestricted license to practice medicine and surgery in PA is essential before beginning fellowship.)

__ Single __ Married/Spouse’s Name_________________ Number of Children ___

__ United States Citizen or __ Other (specify and indicate type of visa held): _______________

Foreign Medical Graduates – ECFMG Examination: (If Applicable)

Date Taken_______________ Scaled Score_________________ Certificate No._____________

___________________________ _____________________________________

Date of Application Signature of Applicant