Fellowship Application

Department of Anesthesia
Penn State Milton S. Hershey Medical Center
Fellowship Admissions Office
The Pennsylvania State University

Name * First Last
Desired Fellowship *
Desired Start Date of Fellowship * / MM / DD YYYY
Contact Information
Email *
Home Phone *

Please enter your phone number without "-".
Cell Phone
Work Phone
Present Mailing Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Permanent Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Citizenship
Are you a citizen of the U.S.? (*Our cardiothoracic anesthesiology fellowship program only accepts permanent residents and U.S. citizens.) Yes No
If not, do you intend to become a citizen of the U.S.? Yes No
If non U.S. citizen, what is your Visa status?
Visa Ending Date / MM / DD YYYY
USMLE/COMLEX Test Scores

Please upload or mail a copy of your exam scores to the fellowship office
I
II
III
Upload USMLE/COMLEX Exam Scores
In-Training Scores (e.g. ABA-ASA)
I
II
III
Medical School
Name
City/State
Type of Degree
Date Degree Obtained / MM / DD YYYY
Licensure
Description
Number
Date of Issue / MM / DD YYYY
State
Transcripts Transcripts are required for Pediatric and Chronic Pain Fellowships. Please request a letter from the Dean of your medical school and official transcripts to be sent directly to:

Penn State Milton S. Hershey Medical Center
Fellowship Education, Anesthesiology Dept
c/o Jodi Verbos, H187
500 University Drive
Hershey, PA 17033
Curriculum Vitae To include: a) previous education, degrees & date obtained; b) previous graduate training; c) work experience, including medical; d) research experience; e) extracurricular activities; f) honors; and g) publications.
Upload CV *
Personal Statement Please explain your choice of career, previous experience in anesthesia and career objectives. (You are not required to name any group or activity which may reveal your race, religion, national origin or gender).
Upload Personal Statement
References (please provide information for three references):

Reference 1 - The first reference should be the Chairman of the department in which you currently work.
Name
Position
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone
Email
Reference 2 - It is advisable for you to request letters from faculty members with whom you have been closely associated.
Name
Position
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone
Email
Reference 3 - It is advisable for you to request letters from faculty members with whom you have been closely associated.
Name
Position
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone
Email
Signature - Your signature below certifies that the information provided on this application is complete and accurate to the best of your knowledge.
Please type your name in the field below. *
Today's Date * / MM / DD YYYY

Fellowship Application

Contact Information

Citizenship

USMLE/COMLEX Test Scores

In-Training Scores (e.g. ABA-ASA)

Medical School

Licensure

Transcripts Transcripts are required for Pediatric and Chronic Pain Fellowships. Please request a letter from the Dean of your medical school and official transcripts to be sent directly to:

Curriculum Vitae To include: a) previous education, degrees & date obtained; b) previous graduate training; c) work experience, including medical; d) research experience; e) extracurricular activities; f) honors; and g) publications.

Personal Statement Please explain your choice of career, previous experience in anesthesia and career objectives. (You are not required to name any group or activity which may reveal your race, religion, national origin or gender).

References (please provide information for three references):

Reference 2 - It is advisable for you to request letters from faculty members with whom you have been closely associated.

Reference 3 - It is advisable for you to request letters from faculty members with whom you have been closely associated.

Signature - Your signature below certifies that the information provided on this application is complete and accurate to the best of your knowledge.