Attach Recent Photograph 2” X 2”
DEPARTMENT OF RADIATION ONCOLOGY
4301
W.
LITTLE
(501)
686-7100
1. NAME ___________________________________________________________________________
Last First Middle
2. PRESENT ADDRESS
__________________________________________________________________________________
__________________________________________________________________________________
PERMANENT ADDRESS
___________________________________________________________________________________
___________________________________________________________________________________
3. TELEPHONE ____________________________ ___________________________________
Home Work
4. Date of Birth _____________________ Place of Birth _________________________________
5. Social Security # _________________________
6. Single ____ Married _____ Dependents ____ Spouse’s Name ________________________
7. Citizenship:
VISA: Permanent _______ Temporary (specify J-1, H-1) ____________________________
Medical Physics Application (cont’d)
8. Undergraduate Education
____________________________________________________________________________________
____________________________________________________________________________________
9. Graduate
Education (Please have original transcript(s)
sent directly from degree granting
Institution)
___________________________________________________________________________________
___________________________________________________________________________________
10. Post-Graduate
Education (Please have original transcript(s)
sent directly from degree granting
institution)
____________________________________________________________________________________
____________________________________________________________________________________
11. Internships, Fellowships (if any)
____________________________________________________________________________________
____________________________________________________________________________________
12. Honors (prizes, scholarships, membership in honorary societies, etc.)
____________________________________________________________________________________
____________________________________________________________________________________
13. Service
Obligations (National Health Service Corps,
Armed Forces Scholarship, State Programs,etc)
____________________________________________________________________________________
____________________________________________________________________________________
14. If you have any physical or emotional problems which might effect your performance as a student, please indicate below and explain on a separate sheet of
paper.
YES ___________ NO ___________
Medical Physics Residency Application (cont’d)
15. Reference information to be arranged by applicant:
A. Letter of recommendation from the Dean of your Graduate Training Program
AND
B. Letters of recommendation from three (3) individuals who are able to evaluate from
first hand knowledge your current and previous performance. Please indicate their names and addresses below
1.__________________________________________________________________________________
2.__________________________________________________________________________________
3.__________________________________________________________________________________
____________________________________________________________________________________
16. Attach a personal statement indicating your reasons for applying for this position
and your career objectives as presently formulated. Other relevant information may be included at your discretion.
I certify that the information submitted on this application is complete and correct to the best of my knowledge. I understand that any false or missing information may disqualify me for this position.
DATE ______________________ Signature____________________________________________
Deadline for
applications to be submitted is February 15.
Candidates will be
contacted for interview by March 15.
UAMS is an Equal Opportunity/Affirmative Action Employer, and therefore does not discriminate on the basis or race, color, religion, national origin, sex, age, or developmental disability.