Stanford Hospital and Clinics

Division of Plastic & Reconstructive Surgery

Application Deadline: September 1st (Application for Cleft-Craniofacial Fellowships from July 1, 2016 to June 30, 2017)

NAME IN FULL ______

Last First Middle

Address (Present)______

______Tel. (AC): ______

Address (Permanent)______Tel. (AC): ______

Date of Birth (For Record Keeping Purposes Only)______SS#: ______

Citizenship ______Parent’s or Spouse’s Name and Address: ______

______

Present and Previous Military Service if Any: ______

Premedical College(s): ______

______No. Yrs ______Graduation Year:____Degree_____

Advanced Studies ______Degree_____

Medical School ______Graduation Year ______Degree_____

Dean ______Address ______

USMLE scores and years:______

______

Residency and Fellowship Programs

Plastic Surgery Residency Program:______

No. Years ______Start Date: ______Completion Date:______

Plastic Surgery Inservice exam scores and years:______

______

Additional Residencies or Fellowships (List program name & type, location, number of years, and dates):

______

Medical Licensure (State and dates): ______

______

Craniofacial Surgery Fellowship Match Number (www.sfmatch.org): ______

Present State of Health: ______

Do you have any physical or mental impairment that substantially limits one or more of your major

life activities? ______

Please enclose a recent 2” x 3” photograph.

A brief biographical sketch (approximately 1 page) written by the applicant should accompany this application. This should include a description of previous research and clinical experience, and an indication of career goals. This application is submitted in accordance with the policies established jointly by the American Hospital Association, American Medical Association, American Protestant Hospital Association, Association of American Medical Colleges, Catholic Hospital Association, Student American Medical Association, and the American Board of Medical Specialties.

Attach Biographical Sketch (separately)

Attach CV

Date______Signature______