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						<span class="pageName"><h1>Summer Fellowship Application</h1></span>
						
							
		<p>PRINT THIS PAGE</p>
<ul>
<li>Print or type all information requested </li>
<li>Return with: 
<ul>
<li>letter of good standing from your dean&nbsp; </li>
<li>personal statement of goals and career objectives (statement should be limited to 1 page)</li>
</ul>
TO: UGME Coordinator, Medical Education - Henry Ford Health System<br />2799 W. Grand Blvd., CFP - 046, Detroit, MI&nbsp; 48202</li>
</ul>
<p>APPLICATION DEADLINE -&nbsp;MONDAY MARCH 1, 2010</p>
<ul>
<li>Participants will be notified in mid-March by email&nbsp;</li>
</ul>
<p>Name:<br />__________________________________________________________</p>
<p>Current Address:<br />__________________________________________________________<br />__________________________________________________________<br />__________________________________________________________</p>
<p>Current Telephone:<br />__________________________________________________________</p>
<p>Email Address:<br />__________________________________________________________</p>
<p>Track for which you are applying:<br />____ Internal Medicine and Subspecialty<br />____ Anesthesia and Surgical Subspecialty</p>
<p>&nbsp;Name &amp; Location of Medical School:<br />__________________________________________________________<br />__________________________________________________________<br />__________________________________________________________</p>
<p>Primary Career Interest:<br />__________________________________________________________<br />__________________________________________________________<br />__________________________________________________________</p>
<p>Primary Research Interest:<br />__________________________________________________________<br />__________________________________________________________<br />__________________________________________________________</p>
<p>Activities:<br />__________________________________________________________<br />__________________________________________________________<br />__________________________________________________________</p>
<p>How did you become interested in HFHS' Summer Fellowship Program?<br />__________________________________________________________<br />__________________________________________________________<br />__________________________________________________________</p>
	
	
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