FAPO FELLOWSHIP APPLICATION

FAPO FELLOWSHIP APPLICATION
PLEASE FOLLOW ALL INSTRUCTIONS AS OUTLINED BELOW.
THE FOLLOWING MATERIALS MUST BE INCLUDED*

SIGNED AND COMPLETED APPLICATIONCOPY OF MEDICAL SCHOOL TRANSCRIPTVERIFICATION OF MEDICAL SCHOOL GRADUATION: COPY OF DIPLOMAVERIFICATION OF ATTENDANCE AT U.S. RESIDENCY PROGRAM: LETTER OF GOOD STANDING FROM DIRECTOR/HOSPITALCURRENT CURRICULUM VITAECURRENT PROFESSIONAL PHOTOONE (1) LETTER OF RECOMMENDATION FROM CURRENT RESIDENCY PROGRAM:
COPY OF MEDICAL SCHOOL TRANSCRIPT*

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VERIFICATION OF MEDICAL SCHOOL GRADUATION: COPY OF DIPLOMA*

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VERIFICATION OF ATTENDANCE AT U.S. RESIDENCY PROGRAM: LETTER OF GOOD STANDING FROM DIRECTOR/HOSPITAL*

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CURRENT CURRICULUM VITAE*

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CURRENT PROFESSIONAL PHOTO*

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ONE (1) LETTER OF RECOMMENDATION FROM CURRENT RESIDENCY PROGRAM:*

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APPLICANT DEMOGRAPHICS:
Name*

First NameLast Name
TODAY’S DATE

MonthDayYear
Date
DATE OF BIRTH*

MonthDayYear
Date
PLACE OF BIRTH*
DRIVER’S LICENSE NO*
ISSUE STATE*
EXPIRATION*

MonthDayYear
Date
HOME ADDRESS*
HOME PHONE*
Format: (000) 000-0000.
WORK ADDRESS*
WORK PHONE*
Format: (000) 000-0000.
E-MAIL ADDRESS*
ETHNICITY*
APPLICANT EDUCATION
UNDERGRADUATE INSTITUTION*
DEGREE*
LOCATION*
DATES ATTENDED (START)*

MonthDayYear
Date
DATES ATTENDED (END)*

MonthDayYear
Date
GRADUATE INSTITUTION
DEGREE
LOCATION
DATES ATTENDED (START)

MonthDayYear
Date
DATES ATTENDED (END)

MonthDayYear
Date
PODIATRIC MEDICAL SCHOOL*
DEGREE*
LOCATION*
DATES ATTENDED (START)*

MonthDayYear
Date
DATES ATTENDED (END)*

MonthDayYear
Date
POST-GRADUATE TRAINING:
RESIDENCY*
LOCATION*
DATES ATTENDED (START)*

MonthDayYear
Date
DATES ATTENDED (END)*

MonthDayYear
Date
RESIDENCY
LOCATION
DATES ATTENDED (START)

MonthDayYear
Date
DATES ATTENDED (END)

MonthDayYear
Date
RESIDENCY
LOCATION
DATES ATTENDED (START)

MonthDayYear
Date
DATES ATTENDED (END)

MonthDayYear
Date
MEDICAL LICENSES:
STATE*
NUMBER*
ISSUE DATE*

MonthDayYear
Date
EXP DATE*

MonthDayYear
Date
STATE
NUMBER
ISSUE DATE

MonthDayYear
Date
EXP DATE

MonthDayYear
Date
NATIONAL BOARD EXAMINATION RESULTS:

Rows	PART I	PART II	PART III
DATE TAKEN
PASS/FAIL

REFERENCES:
RESIDENCY DIRECTOR*
WORK ADDRESS
PHONE*
Format: (000) 000-0000.
NAME
WORK ADDRESS
PHONE
Format: (000) 000-0000.
NAME
WORK ADDRESS
PHONE
Format: (000) 000-0000.
LEGAL HISTORY:
HAS A MEDICAL MALPRACTICE CLAIM/JUDGMENT EVER BEEN FILED/ENTERED AGAINST YOU, OR IS A CLAIM AGAINST YOU SETTLED OR PENDING?*

YESNO
IF YES, THEN PLEASE EXPLAIN THOROUGHLY ON SEPARATE PIECE OF PAPER.
EXPLANATION:

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WHY DID YOU DECIDE TO APPLY FOR A FELLOWSHIP PROGRAM?*
I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND ACCURATE.
PRINT NAME*
Signature*
SIGNATURE DATE

MonthDayYear
Date
Should be Empty:

FAPO FELLOWSHIP APPLICATION

APPLICANT DEMOGRAPHICS:

APPLICANT EDUCATION

POST-GRADUATE TRAINING:

MEDICAL LICENSES:

NATIONAL BOARD EXAMINATION RESULTS:

REFERENCES:

LEGAL HISTORY: