Department of Pharmaceutical Services

Application for Residency

APPLICATION INSTRUCTIONS

PGY2 interview dates will be as arranged with the respective program director. The application is due by midnight on January 4th, 2015. The application will not be considered complete until all required information is received. Please submit the following:

  1. Completed Application
  • Submit electronically
  • Even if some information may be contained on your CV, please fully answer each question
  1. Curriculum Vitae
  • Submit electronically
  • Include schools and universities attended, degrees conferred or anticipated, employment history, honors and awards, rotation experiences, research or teaching experiences, extracurricular activities, and other pertinent information
  1. Letter of Intent
  • Submit electronically
  • Address to program director
  • Include reasons for pursuing PGY-2 residency training, why you are interested in Emory, and short and long-term goals
  1. 3 Recommendations
  • Submit electronicallyor by mail
  • Please send the attached information to individuals providing recommendations. If submitted electronically, it should be from the recommender’s institutional or business email address to verify authenticity
  • At least 1 of the 3 recommendations must be from your PGY-1 program director
  1. Transcript
  • Only transcript from pharmacy school is required
  • Submit electronically or by mail

PLEASE SUBMIT APPLICATION MATERIALS AS FOLLOWS:

Electronic Submissions: / Mail Submissions: (transcript, letters of recommendation)
  • Email to:
/ Steve Mok, PharmD, BCPS (AQ-ID)
  • Attach documents to email (application, CV, letter of intent)
/ Department of Pharmaceutical Services
Emory University Hospital Midtown
  • For recommendations, request recommender attach form to email and send from institutional or business
/ 550 Peachtree Street NE
Atlanta, GA 30308

Applicant Name:

First NameMI Last Name

  1. Applying For:

PGY-1 Pharmacy Practice Residency

PGY-2 Residency in

  1. Mailing Address:

Street:

City: State: Zip Code:

Contact Number: ( ) - E-mail address:

  1. Eligibility:

Are you eligible to work in the United States?Yes No

Do you require sponsorship to work in the United States?Yes No

  1. Degree(s) Earned:

PharmD College: ______Date:

Other (______) College: ______Date:

Other (______) College: ______Date:

  1. Pharmacy-related Employment:

Community

Employer: ______Address:

Position: ______Dates:

Responsibilities:

Hospital

Employer: ______Address:

Position: ______Dates:

Responsibilities:

Other ()

Employer: ______Address:

Position: ______Dates:

Responsibilities:

  1. Prior Residency Experience (PGY2 applicants only):

Institution: Dates:

Program Director:

  1. Licensure:

State(s) of Licensure/Anticipated Board Exam:

  1. APPE Rotations: (please list those taken and those scheduled)

COURSE TITLEAREA OF CONCENTRATIONPRECEPTORDATE

  1. Have you had any pharmacy-related teaching experience? Yes No If yes, briefly describe:
  1. Have you been involved with any pharmacy-related project or research? Yes No If yes, briefly describe:
  1. Recommendations:

List 3 individuals who will be completing recommendations for you

NAMETITLEPHONERELATIONSHIP

By typing my name below, I certify that the information submitted in this application is complete and correct to the best of my knowledge and belief. I grant Emory Healthcare permission, if necessary, to request additional information from previous schools, employers, and preceptors concerning my academic record and professional ability.

Electronic Signature of Applicant: Date:

(please type)

It is the policy of Emory Healthcare not to discriminate on the basis of race, creed, national origin, sex, age, handicap, or veterans status in admission, employment, or other educational activities and programs. Discrimination on the basis of sex is prohibited by Title IX of the Education Amendment of 1972.

Information for Recommenders

Thank you for submitting a recommendation on the applicant’s behalf. Applicants are required to have recommendations by persons who are in a position to evaluate their qualifications for residency training. The recommender is asked to make a frank appraisal of the applicant's character, personality, abilities, and suitability for a pharmacy residency. All information provided will be kept in strict confidence. Please complete and submit this form by January 4th, 2015.

In your letter, please address the following:

  1. the nature of your interactions with the applicant
  2. any special skills you feel would be an asset
  3. any weaknesses you feel may hinder the applicants ability to perform effectively in a residency program and/or the applicant’s areas for improvement.

Letter of recommendation may be submitted either by fax, mail, or electronically. Electronic submission should be sent from your work/business email to verify authenticity. If submitting by mail, please send to:

Steve Mok, PharmD, BCPS (AQ-ID)
Department of Pharmaceutical Services

Emory University Hospital Midtown

550 Peachtree Street NE

Atlanta, Georgia 30308

Electronic submission:

Fax submission:404-686-2177