UCSD Musculoskeletal Radiology

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Fellowship Application Forms
 

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Please print and send this word document

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OLD Form

UCSD

Medical Center APPLICATION FOR MUSCULOSKELETAL FELLOWSHIP

 
Name (Last, First, Middle)

 

 

 Social Security Number
Present Mailing Address Home Telephone

 

 

 

 

 
Business Address Business Telephone

 

 

 

 

 
Sex

 

 Birth Date Birth Place Citizenship Marital Status # of Dependents

 

 
 

TYPE

SCHOOL/HOSPITAL

ADDRESS

DATES ATTENDED

(From – To)

DEGREE/TYPE/

SPECIALTY
PreMed  

 

 

 

 

  

 

 

 

 

 

 

    
 

Medical

  

 

 

 

  

 

 

 

 

 

 

    
 

Graduate

 

 

    

 

 

 

 

 

 

    
 

Internship

 

 

    

 

 

 

 

 

 

    
 

 

Residency

 

    

 

 

 

 

 

 

    
 

Fellowship

 

 

    

 

 

 

 

 

 

    
 
LICENSURE

You must be licensed in the State of California to train as a fellow in Musculoskeletal Imaging. Graduates

of foreign medical schools should research the feasibility of obtaining a State of California medical license.

 
 

LICENSURE

 STATE NUMBER DATE ISSUED STATE NUMBER DATE ISSUED
 
MILITARY SERVICE
Branch

 

 

 Specialty Rank
Dates of Service

 

 

    

 

 

 
Professional References

Name

Title

Address

 

 

 

    

 

 

 

 

    

 

 

 

 

    
 
ADDITIONAL INFORMATION / COMMENTS

 

 

 

 

 

 

 

 

Email address:
Signature Date

 

 

The University of California is an Equal Opportunity / Affirmative Action Employer.

INSTRUCTIONS:

  1. Mail completed application to:

    Donald Resnick, M.D.

    UCSD Teleradiology & Education Center

    8899 University Center Lane., Suite 370

    San Diego, CA  92122

    Phone 858-552-9210

    Fax     858-552-9126

     

  2. Additional Requirements:

    Three Letters of Recommendation

    Curriculum Vitae

    Brief Biographical Sketch &

    Appraisal of Career Direction

    Photograph (Not mandatory but helpful)

     

  3. Point of Contact:

     

    Paradorn Thiel

    Manager of Clinical and Research Education,

    and Immigration Administrator

    Department of Radiology Business Office

    University of California, San Diego

    4094 4th Avenue, Suite 200

    Mail Code: 0834

    San Diego, California 92103

    Telephone: 619-543-7636

    Fax: 619-543-7898

    E-mail: pthiel@ucsd.edu