Applying for:	PGY I_________	PGY II_________	PGY III_________	Other_________

Starting date:	_________________	_________________	_________________	______________

Name:_____________________________________________________Date:______________________________
       (last)         (first)             (middle initial)

Address:______________________________________________________________________________________
                                 (street)

_________________________________   __________________     _____________    _____________________
           (city)                       (state)              (zip code)            (country)

Phone (daytime)______________________ Birth Date ______________ Place of Birth ______________________

Citizenship __________________ If not USA  type of VISA _________Social Security No. _________________

Sex:_____Marital status_______Dependents_________________________________________________________

Military Status_________________________________________________________________________________


Education

        College                 Location            Dates Attended          Degree Awarded 

1. ____________________  _____________________  _______________________  _______________________

2. ____________________  _____________________  _______________________  _______________________ 


           Medical School                   Location                     Dates Attended                 

1. ______________________________  ________________________  ___________________________________ 

Post Graduate Education 
                        Hospital Name           Location       Dates Attended    Degree Awarded 

1.  Internship ____________________________ _________________ ________________ __________________
                (PGY-1, Projected or Completed)

2. Other ________________________________ __________________ ________________ __________________
          (Residency, Fellowship)      


Honors and Awards

1. ___________________________________________________________________________________________

2. ___________________________________________________________________________________________


Scholastic Societies

1. ___________________________________________________________________________________________

2. ___________________________________________________________________________________________


Research Experience

1. ___________________________________________________________________________________________
            (Type)                   (Location)                           (Dates)

2. ___________________________________________________________________________________________
            (Type)                   (Location)                           (Dates)



Examinations

Please indicate the examinations you have taken and your scores (attach copy of Exam Certificate).

                                                  Date:                         Scores:

USMLE I                               __________________________   ____________________________

USMLE II                              __________________________   ____________________________

ECFMG/FMGEMS (Basic Science)          __________________________   ____________________________

ECFMG/FMGEMS (Clinical Science)       __________________________   ____________________________

FLEX                                  __________________________   ____________________________
(State)



Current Employer

____________________________________________________________________________________________
 (Name)                           

____________________________________________________________________________________________
 (Address)

____________________________________________________________________________________________

References

List 4 individuals, including the Dean of your Medical School and your PGY-1 Program  Director
(if applicable) whom you have requested to write this office regarding your personal and
professional qualifications.

1. Name and Title ______________________________________________________________________________

Institution, Address ___________________________________________________________________________

2. Name and Title ______________________________________________________________________________

Institution, Address ___________________________________________________________________________

3. Name and Title ______________________________________________________________________________

Institution, Address ___________________________________________________________________________

4. Name and Title ______________________________________________________________________________

Institution, Address ___________________________________________________________________________


Your Health Status

Do you have any medical or psychological illness that would impair your ability to deliver quality
patient care?  If Yes, please explain:  

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Personal Statement  

Please describe (250 words or less) your professional and personal interests, achievements and 
plans.  List any publications you may have authored and other accomplishments.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________


_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please  enclose copies of your medical school transcripts, graduation certificate, and copies
of your National Board (USMLE)  scores.  Foreign  graduates must also enclose copies of National
Board  (USMLE) or  FMGEM  scores, ECFMG certificate, and their visa.

I certify that the information entered on this application is complete and accurate to the  best
of  my knowledge.  I agree to notify the Neurology Residency Program Director of any circumstances
arising after the date of  this  application which would change my answers.  I grant my permission
for the University of Tennessee,  Department of Neurology to contact any or all of my former 
employers, educational institutions, or individuals named in this application to release any
additional information, in written or verbal form, concerning my application to 
the Residency Training Program.




_____________________  _______________________________________________________________________
       (Date)                                        (Signature)




Please Return Completed Form to:

  Mail:  Attn: Ms. Carol Blackman
         Neurology Residency Training Coordinator
         Department of Neurology
         University of Tennessee Health Science Center
         855 Monroe Avenue, Rm 415
         Memphis, TN 38163
  Email: cblackman@utmem.edu
  Phone  901-448-6661
  Fax:   901-448-7440