The Division of Traumatology, Surgical Critical Care and Emergency Surgery,
Department of Surgery, University of Pennsylvania School of Medicine


2015 Fellowship Program Application

The deadline for this application is July 1, 2014

Effective July 1, 2013, UPHS will cease hiring tobacco users in our efforts to improve
the overall health of our workforce while reducing health care benefit costs.

Fellowship Type:  
Fellowship Desired Start Month/Year:      

Name (F,Mi,L):
Address:
 
City: St/Prov
Zip:
Country:
Phone: Pager:
Fax: Cell:
E-Mail:
Preferred method of contact:


Date of Birth: State of Birth:
Gender:

Country of Birth:
Social  Security: Citizenship:
ACLS Status: ATLS Status:

If a graduate from a foreign medical school, how do you qualify (ECFMG certificate, etc.)?
ECFMG #:    
Visa Type: Visa #:
(If applicable, please send copies of certificates)

Undergraduate Education
Undergraduate College(s) and Location From (Mo/Yr) To (Mo/Yr) Degree
School:
Address:
City: State: Zip:   
Country:  
    
School:
Address:
City: State: Zip:
Country:

Medical Education
Medical School(s) and Location From (Mo/Yr) To (Mo/Yr) Degree
School:
Address:
City: State: Zip:   
Country:  
Accredited?      

School:
Address:
City: State: Zip:
Country:
Accredited?

Graduate Education/Internship/Residency Training
Postgraduate Training and Location From (Mo/Yr) To (Mo/Yr) Specialty
Institution:
Address:
City: State: Zip:    Specialty Board Certified/Admissible? (if yes, please send a copy)
Country:  

Institution:
Address:      
       
City: State: Zip: Specialty Board Certified/Admissible? (if yes, please send a copy)
Country:      

Institution:
Address:
City: State: Zip: Specialty Board Certified/Admissible? (if yes, please send a copy)
Country:

Fellowships
Institution and Location From (Mo/Yr) To (Mo/Yr) Specialty
Name:
Address:
City: State: Zip:    Specialty Board Certified/Admissible? (if yes, please send a copy)
Country:  
     
Name:
Address:      
       
City: State: Zip: Specialty Board Certified/Admissible? (if yes, please send a copy)
Country:      
 

Medical Licenses
Medical License #: Expiration Date:  
State:    

Medical License #: Expiration Date:
State:    

Military Experience
Military Service?

Branch: Current Status:  

References

1 Name: Address:
  Title: City: State:
  Phone: Country:

2 Name: Address:
  Title: City: State:
  Phone: Country:

3 Name: Address:
  Title: City: State:
  Phone: Country:
 

Please forward a copy of the following via e-mail to Linda Laska (laskal@uphs.upenn.edu)
or fax a copy to (215) 349-5917:

* Copy of CV
* 3 Letters of recommendation supporting your application
  Addressed to: Patrick Reilly, MD, FACS
Fellowship Program Director
Traumatology, Surgical Critical Care and Emergency Surgery
University of Pennsylvania Health System
3400 Spruce Street
5 Maloney
Philadelphia, PA 19104
* Current photograph
* Copy of ECFMG certificate, if applicable
* Copies of Certifications for Graduate Programs, Internships, Residencies, and Fellowships, if specialty is board certified/admissible
* (If not provided at the time of the application, will be required at the time of interview)

 Please contact Linda Laska (laskal@uphs.upenn.edu) (215-614-0316) with any questions concerning this application.