The University of Texas-Houston Medical School
Application for Training Program in Hematology

Please fill out the application completely in the spaces provided (NO see resume/curriculum vitae).

Beginning July 1, _____                                                                     Attach photo here
 

Current Post-Graduate Level:_________________________________________________

Name:_______________________________________________ Date of Birth:________________
            Last                                         First                             MI

City, Country of Birth:______________________________________________________________

Social Security #:_____________________________ Marital Status:________________

Citizenship:______________________ If non-citizen, type of Visa:_________________

Mailing Address:__________________________________________________________________

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E-mail Address:___________________________________________________________________

Daytime Telephone:_________________________ Home Telephone:_________________________

Do you hold a current Texas medical license?___________ If yes, number:______________________

EDUCATION

College                                     Location                                 Dates                         Degree
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Medical School                         Location                                 Dates                         Degree
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Internship                                             Chief of Service                                     Dates
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Residency                                             Chief of Service                                     Dates
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Fellowship                                             Chief of Service                                    Dates
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SPECIAL PRELIMINARY EXPERIENCE OR TRAINING IN HEMATOLOGY
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RESEARCH EXPERIENCE
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PUBLICATIONS
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HONORS AND AWARDS
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ECFMG - Certificate Number:_________________________________

USMLE*                                     Year Taken                                Score

    Step I                                    __________                           _____________

    Step II                                  __________                           _____________

    Step III                                __________                            _____________

*Please note: If a fellowship position is offered to you, USMLE Step I, II and III transcripts will be required to be sent directly to:
Ms. Florinda Guerra, Coordinator III, Residency Training, Graduate Medical Education Office
The University of Texas Health Science Center at Houston, Jesse Jones Library
1133 John Freeman Blvd., Suite 310, Houston, Texas   77030 USA

Letter of Reference (in addition to the Dean's letter), have been requested from the following three (3) individuals:

Name                                                     Address                                                 Telephone
1)________________________________________________________________________________
2)________________________________________________________________________________
3)________________________________________________________________________________
 

Applicant's Signature_______________________________________________________________

Mail completed form, a personal statement, Dean's letter and three (3) letters of reference to:

Harinder S. Juneja, M.D., Professor & Director
Hematology Fellowship Program
The University of Texas-Houston Medical School
6431 Fannin, MSB 5th Floor
Houston, TX 77030
Phone: (713) 500-6800

DEADLINE FOR RECEIPT OF COMPLETED APPLICATIONS: OCTOBER 31