APPLICATION FOR POSTGRADUATE TRAINING IN INFECTIOUS DISEASES

DIVISION OF INFECTIOUS DISEASES
Department of Medicine

Washington University School of Medicine
Campus Box 8051/660 S. Euclid
St. Louis, Missouri 63110-1093

Fellowship application for July _________

Date _________________

Name _______________________________________________________________________
Last First Middle

Social Security Number ________ - ________ - ________

Addresses: (Home) __________________________ (Office) __________________________

__________________________ __________________________

Telephone: (_______)__________________ (________)_________________

Three letters of reference are required. The responsibility for securing letters of reference rests with the applicant and all letters of reference should be forwarded directly to William Powderly, M.D., Division of Infectious Diseases. Kindly list the names and titles of the three individuals form whom we may expect letters of reference.

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

Signed: _____________________________

This form should be returned with:

1. a current curriculum vitae

2. a statement of career interests