UCSD Musculoskeletal Radiology

bonepit.com

Fellowship Application Forms

 

Fellowship program homepage.
 

Homepage

Please print and send this word document

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OLD Form

UCSD

Medical Center APPLICATION FOR MUSCULOSKELETAL FELLOWSHIP

 

Name (Last, First, Middle)

 

 

Social Security Number
Present Mailing Address Home Telephone

 

 

 

 

 

Business Address Business Telephone

 

 

 

 

 

Sex

 

Birth Date Birth Place Citizenship Marital Status # of Dependents

 

 

 

TYPE

SCHOOL/HOSPITAL

ADDRESS

DATES ATTENDED

(From – To)

DEGREE/TYPE/

SPECIALTY

PreMed  

 

 

 

 

 

 

 

 

 

 

 

   
 

Medical

 

 

 

 

 

 

 

 

 

 

 

   
 

Graduate

 

 

   

 

 

 

 

 

 

   
 

Internship

 

 

   

 

 

 

 

 

 

   
 

 

Residency

 

   

 

 

 

 

 

 

   
 

Fellowship

 

 

   

 

 

 

 

 

 

   
 
LICENSURE

You must be licensed in the State of California to train as a fellow in Musculoskeletal Imaging. Graduates

of foreign medical schools should research the feasibility of obtaining a State of California medical license.

 
 

LICENSURE

STATE NUMBER DATE ISSUED STATE NUMBER DATE ISSUED
 
MILITARY SERVICE
Branch

 

 

Specialty Rank
Dates of Service

 

 

   

 

 

 

Professional References

Name

Title

Address

 

 

 

   

 

 

 

 

   

 

 

 

 

   
 
ADDITIONAL INFORMATION / COMMENTS

 

 

 

 

 

 

 

 

Email address:

Signature Date

 

 

The University of California is an Equal Opportunity / Affirmative Action Employer.

INSTRUCTIONS:

  1. Mail completed application to:

    Donald Resnick, M.D.

    VA San Diego Healthcare System

    Department of Radiology (114)

    3350 La Jolla Village Drive

    San Diego, CA 92161

     

  2. Additional Requirements:

    Three Letters of Recommendation

    Curriculum Vitae

    Brief Biographical Sketch &

    Appraisal of Career Direction

    Photograph (Not mandatory but helpful)

     

  3. Point of Contact:

    Secretary to Dr. Donald Resnick

    VASDHS – Radiology 114

    3350 La Jolla Village Drive

    San Diego, CA 92161

    858-552-8585 ext 3343

    858-552-7565 fax

    SDCVAMCRadiologyFellowshipProgram@va.gov

     

     

  4. We are now in the fellowship match program.