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Resident Program
DEPARTMENT OF OTOLARYNGOLOGY / HEAD & NECK SURGERY
TEMPLE UNIVERSITY
RESIDENCY PROGRAM APPLICATION

Last name:
 First name:
 Middle name:
Email address:

 

CURRENT ADDRESS
Street:
 City:
 State:
ZIP:
 Country:
 Telephone:

 

PERMANENT ADDRESS
Street:
 City:
 State:
ZIP:
 Country:
 Telephone:
Send mail to: Current Address Permanent Address

 

Date of Birth (optional):
 Place of Birth: City
 Place of Birth: Country
NRMP#:
 Social Security No.:

 

Are you a citizen or permanent resident of the United States?
YES   NO   If no, please supply information regarding visa status and authorized length of stay in the U.S. via Fax.

 

Undergraduate College:
 Dates:
  
Graduate School:
 Dates:
 Degree:
Medical School:
 Dates:
  

 

References (those sending letters of recommendation)
l.
2.
3.

Please check one of the following:
waive access to the above letters and will so inform the author.
desire access to the above letters and will so inform the author.

 

Which of these examinations have you taken? (Indicate all parts taken, dates, and results)
National Board of Medical Examiners (NBME)
Part I
Date:
Result: 		Part II
Date:
Result: 		Part III
Date:
Result:
United States Medical Examination (USMLE)
Step I
Date:
Result: 		Step II
Date:
Result: 		Step III
Date:
Result:
Federation Licensing Examination (FLEX)
Part I
Date:
Result: 		Part II
Date:
Result: 		Other (specify)

 

Have you ever been dismissed from a professional or educational position?
  NO   YES
If yes, please provide explanation:

 

Are you currently dependent on alcohol or drugs?   NO   YES
If yes, please provide explanation:
If your answer to any question in this application requires an explanation, please use this space:

 

I certify that to the best of my knowledge, the information provided in this application is true.

 

(You may submit this form. Additionally, please print it, sign it and fax or send it via mail to (add signature and a photo):

Otolaryngology Department
Temple University School of Med.
3400 N. Broad St.
1st flr.-Kresge West Bldg.
Phila., PA 19140
ATTN: RESIDENCY APPLICATION


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 Department Phone:
215 - 707 3663

 Department Fax:
215 - 707 7523

Resident Application
Background information
Information for applicants
Residency program assessment
Online application form
Current residents

Grand rounds and Lectures

Grand round presentations

More about:
Research
Grants
Publications
 


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