Name: ________________________________________________________________

Age: __________________________________________________________________

1. Please outline your present plans for postgraduate training.
   
   
   
   
   
   
2. What are your ultimate goals in medicine?
   
   
   
   
   
   
3. Have you completed a research project while in medical school?
   
   
   
   
   
   
4. Please add other information you feel would help us further your candidacy (i.e., Board scores, Committees, community services, hobbies, honors, awards, letters of distinction, etc.)
   
   
   
   
   
   
5. Comment on any restrictions, etc. in your applying for residency training
   (i.e. being restricted to So. Calif., Nat'l Health Service commitment, etc)
   
   
   
   
   
   

Documents needed for Chair's Letter

1. This Form
2. C.V.
3. Personal Statement