Fellowship Application

Rehabilitation Institute of Chicago
Department of Physical Medicine & Rehabilitation
Northwestern University Feinberg School of Medicine
345 East Superior Street
Chicago, Illinois 60611

*Note: It is the responsibility of the applicant to request a letter of recommendations from their listed references. Letters of recommendation to should be mailed to Rita Bailey, Rehabilitation Institute of Chicago, 345 E. Superior Street- Suite #1600, Chicago, IL. 60611

Sports Medicine/Musculoskeletal Rehabilitation, Pediatric Rehabilitation, and Chronic Pain Management Fellowships (CLOSED): Deadline- August 1, 2009

*Please allow 20-30 minutes to complete the form. In addition, please have your completed personal statement, curriculum vitae, and all your contact information for your references ready to complete the fellowship application.

Select Fellowship:

TRAUMATIC BRAIN INJURY FELLOWSHIP

Contact Information:

First Name*

Last Name*

Degree (MD/DO)*

Address*

Apt/Suite

City*

State

ZIP code *

Country

Telephone*

E-mail*

Undergraduate Education:

Name of Institution*

City*

State

Country

Graduation Date (MM/DD/YYYY)*

Degree*

Medical School Education:

Name of Institution*

City*

State

Country

Graduation Date (MM/DD/YYYY)*

Degree*

Residency Training (Intern or Trasitional Year):

Name of Institution*

City*

State

Country

Start Date (MM/DD/YYYY)*

End Date (MM/DD/YYYY)*

Residency 2:

Name of Institution

City

State

Country

Start Date (MM/DD/YYYY)

End Date (MM/DD/YYYY)

ABMS Board Certifications:

Specialty 1

Year of Certification

Certificate Number

Specialty 2

Year of Certification

Certificate Number

Personal Statement and Curriculum Vitae:

Note: The personal statement should include: A) Your professional goals B) Why your are applying for this fellowship and C) What you hope to gain from this experience.

Personal Statement*

Curriculum Vitae*

State Medical Licenses:

Illinois Permanent Medical License

IL License Number

Date Issued (MM/DD/YYYY)

Expiration Date (MM/DD/YYYY)

Current State Medical License 2 (no need to complete if you already have a permanent Il Medical License)

Current State License Number

State

Date Issued (MM/DD/YYYY)

Expiration Date (MM/DD/YYYY)

References: (Please send letters of recommendation to the Department of PM&R to complete your application.)

Reference 1:

Name*

Title *

Address*

City*

State

ZIP code *

Country

Telephone*

E-mail*

Reference 2:

Name*

Title *

Address*

City*

ZIP code *

State

Country

Telephone*

E-mail*

Reference 3:

Name*

Title *

Address*

City*

State

ZIP code *

Country

Telephone*

E-mail*

IMPORTANT REMINDER: PLEASE SEND LETTERS OF RECOMMENDATION FROM YOUR PRECEPTORS/LISTED REFERENCES AS SOON AS POSSIBLE TO COMPLETE YOUR APPLICATION.