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Last Name
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First Name
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Address1
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Address2
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city
state
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zipcountry
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Telephone
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Citizenship
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Date of Birth:
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Application
For:
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High
School
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Name:
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City:
State:
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Date of Graduation:
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Premedical
College or University
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Name:
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City:
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State:
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From:
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To:
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Major:
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Medical College
or University
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Name:
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City:
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State:
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From:
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To:
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Special Honors:
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General scholastic standing:
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Do you have or have you ever had a congenital,
chronic, or debilitating disease? If yes please explain:
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Graduate Medical
Education
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INTERNSHIP HOSPITAL
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Type:
City:
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State:Dates:
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Previous Residency Training:
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Place:
Type:
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Dates:
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Past Research(describe briefly)
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Past teaching experience
(describe briefly)
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List the names of states you are licensed to
practice
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Has your license ever been revoked?
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If yes Please explain
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Publications
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Relevant work experience
(names, locations, positions, and dates)
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Future
Psychiatric Specialty Interests
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To what Journals do you subscribe?
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To what organizations do you belong?
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What are your hobbies and recreational interests?
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What are the motivating factors which prompted you to
seek psychiatry residency trancing? List TWO
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Reason 2
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Preferred dates
for starting Psychiatric Residency Training (please check
below)
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Time of Year:Year
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If you are participating in the match please include you
NRMP number
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NRMP #
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If your spouse is participating in the couples match
please indicate your spouses specialty
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Specialty:
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Please include the following items
with your completed application form or mail to Dr. D. Allen
(see address below)
1. A curriculum vitae.
dmallen@utmem.edu
2. A personal statement (At least one typewrtten page).
dmallen@utmem.edu
( If you wish to include a personal statement
type on personal statement
page and SUBMIT)
In addition to a letter of reference
from the Dean of your medical school, you should request
that at least three letters of recommendation be sent from
the following:
1. Two faculty members you have worked with
and who know you.
2 A senior staff member under whom you worked as an
intern.
3 Director of Residency Training Program if applying for
PGY- 2 position.
4. A psychiatrist who may or may not have been a member
of your medical school faculty.
5. Anyone else you feel is appropriate as a character
reference.
Also send:
6. An original copy of your transcript from
your medical school.
7. An copy of your undergraduate transcript (Foreign
Medical Graduates only)
TO:
To: Dr. David Allen
Psychiatric Residency Training Program
135 North Pauline, 6th Floor
Memphis, Tennessee 38105
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Foreign Medical
Graduates
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What type of Visa do you have?
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Visa number:
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For more information
CONTACT
David Allen, M.D., Director
Psychiatric Residency Training Program
135 North Pauline, 6th Floor
Memphis, Tennessee 38105
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