APPLICATION FOR LOW VISION ADVANCED SPECIALTY TRAINING
(“FELLOWSHIP”) PROGRAM AT THE WILMER EYE INSTITUTE
JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
1. NAME: ______________________________________ _________________________ ____________
Last First Middle
2. DEGREE(S): _____________________________________________________________________________
3. HOME ADDRESS: _____________________________________________________________________
_______________________________________________________________________________________
EMAIL: _______________________________________________________________________________
PHONE: ___________________________________PAGER: ___________________________________
FAX: ______________________________________ CELL: ____________________________________
4. HONORS & AWARDS: _________________________________________________________________
_______________________________________________________________________________________
5. UNDERGRADUATE SCHOOL: __________________________________________________________
MAILING ADDRESS: ___________________________________________________________________________________
MONTHS/YEARS ATTENDED: ______________________________DEGREE(S) CONFERRED:_______________________
6. MEDICAL/OPTOMETRY SCHOOL: _____________________________________________________
MAILING ADDRESS: _____________________________________________________________________________________
MONTHS/YEARS ATTENDED: ______________________________DEGREE(S) CONFERRED:_______________________
7. OTHER TRAINING (PHD, MS, MPH): ____________________________________________________
MAILING ADDRESS: _____________________________________________________________________________________
MONTHS/YEARS ATTENDED: ______________________________DEGREE(S) CONFERRED:___________N/A________
8. INTERNSHIP: _________________________________________________________________________
MAILING ADDRESS: _____________________________________________________________________________________
MONTHS/YEARS ATTENDED: ______________________________DEGREE(S) CONFERRED:____________N/A_______
9. RESIDENCY: __________________________________________________________________________
MAILING ADDRESS: _____________________________________________________________________________________
MONTHS/YEARS ATTENDED: ______________________________SERVICE OR SUBJECT:_____________N/A_________
10 . PROFESSIONAL REFERENCES : (three letters of recommendations from clinical mentors or
experienced colleagues).
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Phone: _________________________________Email: ________________________________________
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Phone: _________________________________Email: ________________________________________
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Phone: _________________________________Email: ________________________________________
11. LICENSING EXAMINATIONS:
Date Completed _____________ Score: ______/______% No. Times Taken ______
Date Completed _____________ Score: ______/______% No. Times Taken ______
Date Completed _____________ Score: ______/______% No. Times Taken ______
For Foreign Medical School Graduates:
ECFMG No.: ______ (Please attach a copy of the certificate)
12. I am licensed in the State(s) of: __________________________________________________________
13. NON-U.S. CITIZENS ONLY : Do you have a visa? ___________________
If yes, please complete the following: Expiration Date: _______________________
Visa Type: ________________________ Alien Registration No.: _________________
Entrance Date into U.S.: _____________ Do you have permission to work? _________
Do you have INS permission to be involved in direct patient care? _________________________
Is your degree of patient care involvement limited by your visa? ___________________________
Proposed career plans following completion of your fellowship. (Use no more than one page for this.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Application Deadline: January 30, 2009
(July1, 2009 – June 30, 2010 Academic year)
Return with Curriculum Vitae and Photograph (passport style) to:
Dr. Judith E. Goldstein, Wilmer Eye Institute,
550 N. Broadway, 6 th Floor, Baltimore, MD 21205
Phone: 1.410.955-0580
The information below will not be attached to your application materials and is used only for statistical purposes required by the Johns Hopkins University School of Medicine.
• DATE OF BIRTH: ____________________________
• PLACE OF BIRTH: ___________________________
• CITIZENSHIP: _______________________________
• GENDER: c MAN c WOMAN
• ETHNICITY/RACE: __________________________
• Do you consider yourself to be Hispanic or Latino? (See definition below.) Select one.
Hispanic or Latino . A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.
c Hispanic or Latino
c Not Hispanic or Latino
2. What race do you consider yourself to be? Select one or more of the following.
c American Indian or Alaska Native . A person having origins in any of the original peoples
of North, Central, or South America, and who maintains tribal affiliation or community
attachment.
c Asian . A person having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Phillippine Islands, Thailand and Vietnam.
(Note: Individuals from the Phillippine Islands have been recorded as Pacific Islanders in
previous data collection strategies.)
c Black or African American . A person having origins in any of the black racial groups of
Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black” or
“African American.”
c Native Hawaiian or Other Pacific Islander . A person having origins in an of the original
peoples of Hawaii, Guam, Samoa or other Pacific Islands.
c White . A person having origins in any of the original peoples of Europe, the Middle East,
or North Africa.
c Check here if you do not wish to provide some or all of the above information.
Please attach a recent Photograph (passport style)