SynerGrx Post-Graduate Application

Post-Graduate Year 1 (PGY1) Resident Application

Post-Graduate Year 1 (PGY1) Resident Application
The application must be submitted and completed by the application deadline.

In addition to completing this application form, you will be asked to:
- upload a letter of intent
- upload an updated curriculum vitae in PDF format
- provide the names and email addresses of three (3) references
- request a formal transcript from your academic institution be sent electronically or mailed
You will be notified of the time and location for a personal interview, should one be required.
Select the academic year you are applying to for your post-graduate program with SynerGrx.*
Name*

First NameLast Name
If you have used or been known by any other name, please give details: (e.g., maiden name)
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country of Birth*
Are you a US Citizen?*
Current Visa
If you are not currently a US citizen, please list your current visa status.

Colleges Attended/Currently Attending (list your highest degree first)*

If yes, you are able to communicate in language(s) other than English, please provide clarification utilizing the table below:

Do you have any limitations or situations which may affect your performance as a post-graduate?*
If yes, please provide details:
Long-Term CarePain ManagementPrimary CarePsychiatry
Upload Curriculum Vitae*

Upload a PDF of your curriculum vitae.
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Upload Letter of Intent*

Upload a PDF of your Letter of Intent.
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Applicant has requested a formal transcript from his/her current academic institution be sent electronically or mailed to Drew W. Cates?*
Candidate understands application is incomplete if formal transcript not received by application deadline.
Direct references to send their letter of reference to:

Drew W. Cates, PharmD, AAHIVP

Director of Education | SynerGrx

phone: 404-590-0509

email: drew@synergrx.com

address: 2342 Perimeter Park Dr, Chamblee, GA 30341

Utilziing the table below, provide the following information for each reference:
- first name
- last name
- credentials (i.e., PharmD, BCPS, etc.)
- title (i.e., Director of Ambulatory Care Services)
- name of institution (i.e., SynerGrx)
- email address
This information is being requested to ensure emails from letters of reference do not end up in spam folders.

References*

Additional questions you have about the post-graduate program with SynerGrx? (one (1) question per box)
I have read and agree to the above statement
Application Signature*

Clear
Should be Empty:

First Name

Credentials (i.e., PharmD, BCPS, etc.)

Name of Institution (i.e., SynerGrx)

Email Address