Date:

SS#:

Date of Birth:

Present Address:
Enter Street, City, State, Zip.

Present Phone:

Permanent Address:
Enter Street, City, State, Zip.

Permanent Phone:

Email Address:

Date Appointment Desired:

EDUCATION [list all schools attended]:

Undergraduate Education:
For each one list: Dates Attended, Institution/Location, Major, Degree & Date

Graduate Education and/or Medical School:
For each one list: Dates Attended, Institution/Location, Major, Degree & Date

AWARDS AND HONORS (highlights):

RESEARCH EXPERIENCE/PUBLICATIONS:

REFERENCES:
List the names & addresses of two (2) persons from whom we will recieve recommendations on your behalf:
1.

2.


DOCUMENTATION REQUIRED:
Complete and submited online application, together with:
    1. A PERSONAL STATEMENT of your plans for postgraduate training
    and future career plans.
    Formatting: Not more than 3 pages, single-spaced, 11-point font,
    with header and footer indicating your name and page number
    (Page X of Y).

    2. A CURRENT CURRICULUM VITAE
    Formatting: Please add hheader and footer indicating your name and
    page number (Page X of Y).

    Email the above documents to:

    lpradhan@bidmc.harvard.edu

    or send to:

    Leena Pradhan, PhD
    William J. von Liebig Summer Research Fellowship
    BIDMC Vascular Surgery Research-East Campus
    330 Brookline Ave. Dana 805
    Boston, MA 02215

    3. Completed applications must include the following three (3) items:
    a) Dean/Advisor or Program Director's Letter (letter of good standing)
    (Hard Copy only no email)
    b) Two additional letters of recommendation (Hard Copy only no email)

These documents should be sent to the Program directly, at the address listed above.

Application DEADLINE for summer 2011: January 10, 2011

Harvard Medical School and participating institutions prohibit discrimination on the basis of race, color, national origin, marital status, religion, gender, age, physical or mental handicap, and status as a disabled veteran or veteran of the Vietnam era. This policy extends to all rights, privileges, programs and activities.

You will receive a copy of your submission by email.