ࡱ> bhc'` UWbjbj$$ 4dFFx2222222FnnnnDF4h b"b"b"b"b"N$ Z%3333333$6hm83]2,b"b",,322b"b"W4---,2b"2b"3-,3--(022P0b"~ n,(@00$m404H09,9P092P0`%':-()%%%33u-%%%4,,,,FFFD FFFFFF222222 Wake Forest University School of Medicine Department of Radiology Medical Center Boulevard Winston-Salem, North Carolina 27157-1088 ATTACH RECENT PHOTO HERE  Application for Vascular Interventional Radiology Fellowship Program Proposed Beginning Date of Training:  FORMTEXT       Full Name:  FORMTEXT       Present Address:  FORMTEXT        FORMTEXT        FORMTEXT       Street City/State Zip Telephone:  FORMTEXT        FORMTEXT        FORMTEXT       Daytime Evening Email Social Security #  FORMTEXT       Citizenship:  FORMTEXT       Place of Birth:  FORMTEXT       Date of Birth:  FORMTEXT       Government Obligations (Public Health Services, etc.) Premedical Education (List Colleges, Degrees and Dates) Medical School and Dates: Achievements (Awards, Honorary Societies, etc): Post Doctoral Experience (Internship, Residency, Fellowship, Private Practice and Dates): Publications: Professional plans after completion of fellowship program:  FORMCHECKBOX  Teaching  FORMCHECKBOX  Private Practice  FORMCHECKBOX  Generalist  FORMCHECKBOX  Research FORMCHECKBOX  Specialist States in which you have a full active medical license: If you answer yes to any of the following questions, give full details on separate sheet.YesNo1. Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked? FORMCHECKBOX  FORMCHECKBOX 2. Have you ever been refused membership in a hospital medical staff? FORMCHECKBOX  FORMCHECKBOX 3. Has your request for any specific clinical privileges ever been denied or granted with stated limitations? FORMCHECKBOX  FORMCHECKBOX 4. Have your privileges at any institution ever been limited, restricted, or revoked? FORMCHECKBOX  FORMCHECKBOX 5. Has your narcotics registration ever been suspended or revoked? FORMCHECKBOX  FORMCHECKBOX 6. Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any medical organization? FORMCHECKBOX  FORMCHECKBOX 7. Have you been diagnosed with or do you have a medical condition which limits orimpairs your ability to practice medicine? FORMCHECKBOX  FORMCHECKBOX 8. Have you engaged in the use of any chemical substance(s) which in any wayinterfered with your abilities to practice medicine? FORMCHECKBOX  FORMCHECKBOX Name, Address and Telephone number of Radiology Residency Program Director: In support of this application, please submit: Letter of recommendation from the Director of your Residency Program )*  # $    , . B D F P R T V \ ݴݢݴ~ݴl#jXhUUhPCJUaJ#jvhUUhPCJUaJ"jhPCJUaJmHnHu#jhUUhPCJUaJjhPCJUaJh/Ybh/Yb5CJaJh/YbhP5CJaJ hP<hPCJaJ hP5\hPhGCJaJhPCJaJ** $IfgdPgdPfkd$$If0N$  634ap $$Ifa$gdP UW \SJ $IfgdP $IfgdPPkd$$If$h  634ap yt/Yb $$Ifa$gd/YbGkd$$If$h634ap yt/Yb   T V \ & _Gkd$$If$h634ap yt/Yb $IfgdP $IfgdPGkd$$If$h634ap yt/Yb & ( < > @ J L $ & ( . F H \ ^ ` j l >@TVXbdRTV\ٵٱٱٍٟ{ٱٱ#j hUUhPCJUaJ#jhUUhPCJUaJ#j"hUUhPCJUaJhP#j@hUUhPCJUaJ#jhUUhPCJUaJhPCJaJ"jhPCJUaJmHnHujhPCJUaJ0& ( . 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Signature of Applicant: _________________________________________ Date: _______________________Enclosures: Curriculum Vitae Personal StatementCompleted applications should be mailed to the appropriate fellowship director at the address listed below:Wake Forest University School of Medicine Attn: Ms. Lucy Rossi Department of Radiology Medical Center Boulevard Winston-Salem, North Carolina 27157-1088Neuroradiology Radiology Program Director:Michael Zapadka, D.O.Fellowship Application Form Revised: February 21, 2011 Copyright: Wake Forest University School of Medicine Department of Radiology All rights reserved. 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