Application Deadline 1/5/2015
Campbell University College of Pharmacy & Health
Sciences and Duke University Hospital
Specialty Residency in Internal Medicine/Infectious Disease/Academics
Application
Campbell University offers equal opportunities to all applicants without regard to race, color, creed, sex, age, handicap, or national origin. The
questions concerning race, sex, and national origin on this application form are for the purpose of meeting Federal reporting requirements.
Legal Name:
(Last)
Gender:
(First)
M
F
Place of Birth:
City
(Middle/Maiden)
Date of Birth:
Mo
State
Day
(Suffix)
Year
Country of Citizenship
If you are a U.S. resident but not a U.S. citizen, what is your visa status?
How long have you lived in the U.S.?
Mailing Address:
Number and Street
(
)
Telephone (best contact number)
City
(
)
Alternate contact number
State
Zip
Email:
Race:
Asian or Pacific Islander
Native American (Eskimo/Indian)
Hispanic
Black/African American
Caucasian
Other:
For identification and interview purposes
only, please attach a recent photograph
of yourself in the box provided.
Write your name on the
back of your photograph
Attach Photo
Here
Application Deadline 1/5/2015
Briefly answer the following questions.
1.
Why are you interested in pursuing our specialty residency program?
2.
What characteristics/traits to you possess that would make you an excellent resident for our program?
3.
Briefly describe your prior pharmacy residency or fellowship experience (requirements, rotations, accreditation if
applicable).
4.
Briefly describe your immediate (post‐residency) and long‐term career goals.
Application Deadline 1/6/2014 List
References
Name/Title
Institution/Address
Phone
Email
Applicant Signature:
Date:
Letters of Recommendation
Applicants to this Specialty Residency should submit letters of recommendation by persons able to
evaluate your qualifications for residency training. Please ask your reference provider to submit a letter
of recommendation on your behalf. Letters can be sent via regular mail or preferably via email to
[email protected]