application for fellowship in

PSYCHOSOMATIC MEDICINE

LSUHealthSciencesCenter

Department of Psychiatry

NAME IN FULL ______

CURRENT ADDRESS ______

______

AREA CODE ______TELEPHONE NO. ______

START DATE FOR FELLOWSHIP ______

Attach photo above

STARTING AS PGY-V? _____ PGY-VI ______PGY-VII ______

(If applying while still in a training program, please have your training director provide a letter, in addition to your three letters of recommendation, that documents your expected completion date and all courses and rotations that you will have completed by the end of your PGY-IV year.)

PERMANENT ADDRESS ______

______

STATE AND DRIVER’S LICENSE NO. ______

DATE OF BIRTH ______PLACE OF BIRTH ______SEX ____

SOCIAL SEC # ______CITIZEN ______

EDUCATION (List all schools and locations; include dates, degrees, major and minor. Attach a CV, but you must still fill out the following.)

  1. UNDERGRADUATE ______

______From ______to ______

  1. MEDICAL ______

______From ______to ______

  1. GRADUATE or PROFESSIONAL (non-medical) ______

______

  1. HONORS (List all professional and academic honors and awards.) ______

______

  1. INTERNSHIP ______From ______to ______
  1. RESIDENCY ______From ______to ______
  1. RESIDENCY ______From ______to ______

PUBLICATIONS (Provide journal references and enclose reprints of up to two articles. May reference CV if more than three articles.)

______

______

______

CURRENT STATE LICENSES (You will need to acquire a Louisiana Medical License.)

______Number ______Exp ______

______Number ______Exp ______

DESCRIBE BRIEFLY EXPERIENCE IN PSYCHOSOMATIC MEDICINE UP TO NOW

______

______

REFERENCES (Please have three professionals who are familiar with your work and qualities send us a letter of reference. Ask them to address your experience and/or interest in psychosomatic medicine. Please send us a copy of your Dean’s letter from medical school graduation. Below list the name, title, address, phone number of each person.)

  1. ______

______

  1. ______

______

  1. ______

______

SIGNATURE OF APPLICANT ______DATE ______

Please enclose a brief essay, 500 words or less, describing your background and the development of your interest in psychosomatic medicine, including your future plans. Please enclose your CV, and 1-2 articles published if available. Please keep us notified of changes in address or phone numbers by email. When your application is complete, it will be reviewed. We will notify you for interviews. Dr. Conrad can be reached at . The program does not discriminate with regard to gender, race, age, religion, color, national origin, disability, veteran status, or sexual orientation.All materials requested including application should be mailed to:

Program Director, Psychosomatic Medicine Fellowship

Department of Psychiatry, LSUHealthSciencesCenter

1542 Tulane Avenue 2nd Floor

New Orleans, Louisiana70112

(504) 568-7912 phone

(504) 568-6006 fax

Revised July 2008 Page 1 of 3