Oncology Fellowship Application


Name:

Current Address:

City:

State:

Zip Code:

Phone:

Alternate Phone:

US Social Security Number:

Email:

Permanent Address:

City:

State:

Zip:

Country:

Permanent Phone:

Birthplace:

Birthdate:

Gender:

Citizenship:

Education

Undergraduate and Graduate Schools

Dates From/To:	School Name:	State:	Degree:	GPA:

Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:

Dental Schools Attended

Dates From/To:	School Name:	State:	Degree:	GPA:

Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:

Post Doctoral Programs Attended

Dates From/To:	School Name:	State:	Degree:	GPA:

Dates From/To:	School Name:	State:	Degree:	GPA:
Dates From/To:	School Name:	State:	Degree:	GPA:

National Board Examination Scores

Average Part I:
Average Part II:

Regional Board Examinations that you have taken and passed

1:
2:
3:

Supplemental Questions

Note: All questions must be answered.

Have you ever practiced dentistry?

If yes, please describe:

Are you licensed to practice dentistry?

If yes, please describe:

Do you have research or teaching experience?

If yes, please describe:

Do you have military or public health experience?

If yes, please describe:

Are you currently under charge?

If yes, please describe:

Do you have previous felony charges?

If yes, please describe:

Were you ever the recipient of disciplinary action by an educational instutition?

If yes, please describe:

Have you ever been subject to disciplinary action by a licensing board?

If yes, please describe:

Are you licensed to practice another profession?

If yes, please describe:

Please compose a statement of purpose.

Written/Mailed Materials Required:

Dental School Transcripts
Medical School Transcripts (If Applicable)
CV
A 2" X 2" Photo

Letters of Recommendation from:

Oral and Maxillofacial Surgery Program Director
Dean of your Dental School
Dean of Medical School (If Applicable)
2 Letters from Dental/Medical School Faculty or Residency Faculty

Please submit all materials by Postal Mail or email to:

Carolyn Campbell
OMSHD, Room 2008
Ann Arbor, MI 48109-1078

You may also contact the program coordinator directly at:
e-mail: cmcamp@umich.edu
Phone: 734-615-8606
Fax: 734-615-1415

Oral & Maxillofacial Surgery / Hospital Dentistry

Education

Undergraduate and Graduate Schools

Dental Schools Attended

Post Doctoral Programs Attended

National Board Examination Scores

Regional Board Examinations that you have taken and passed

Supplemental Questions

Note: All questions must be answered.

Have you ever practiced dentistry?

Are you licensed to practice dentistry?

Do you have research or teaching experience?

Do you have military or public health experience?

Are you currently under charge?

Do you have previous felony charges?

Were you ever the recipient of disciplinary action by an educational instutition?

Have you ever been subject to disciplinary action by a licensing board?

Are you licensed to practice another profession?

Please compose a statement of purpose.

Written/Mailed Materials Required:

Please submit all materials by Postal Mail or email to: