APPLICATION FOR FELLOWSHIP

Universal Application is also accepted

Please print, type, complete and return this two page document by post.
(E-Submissions can not be accepted at this time).

Send all information to the following address:

TAOS ORTHOPAEDIC INSTITUTE
1219-A GUSDORF ROAD
TAOS, NEW MEXICO 87571

Questions? Call Toll Free (888) 758-0009

In addition to the documents requested in the body of the application,
please attach the following:

1. A recent (within one year) photograph

2. A current copy of your curriculum vitae

3. A personal statement

Date__________________________________________________________________________

Name _________________________________________________________________________

Mailing Address:_______________________________________________________________________

______________________________________________________________________________

SSN:__________________________________________________________________________

Birth Date_____________________________________________________________________

Citizenship:____________________________________________________________________

Home Telephone:_______________________________________________________________

Institution Telephone:____________________________________________________________

Current Position:________________________________________________________________

(e.g. Resident PG Year Private Practice, etc)

Address______________________________________________________________________

Office Fax____________________________________________________________________

E-Mail_______________________________________________________________________

Personal Information

Marital status:________________________________________________________________

Name of Spouse_______________________________________________________________

Names and ages of children_____________________________________________________

Number of adult dependants (excluding spouse)_____________________________________

Housing requirements (# of bedrooms, handicap or special access, etc.)_________________

____________________________________________________________________________

Personal Health:______________________________________________________________

Height________________________________Weight:________________________________

Education and Training

* Undergraduate Institution:_______________________________________________

Dates:______________________Degree:____________Major:__________________

* Medical School:________________________________________________________

Dates:______________________Degree:___________Major:___________________

* Internship:____________________________________________________________

Dates:______________________Type______________________________________

* Residency:___________________________________________________________

Dates:______________________Type:_____________________________________

* Fellowship:___________________________________________________________

Dates:______________________Type:_____________________________________

* Other:_______________________________________________________________

Dates:______________________Type:_____________________________________

* Board Certification Status:______________________________________________

* Current Medical Licenses:______________________________________________

* Please attach photocopies of diplomas, certificates, or letters from the institution for verification.

Name and phone numbers of three professional references ( have letters sent directly to us).

1. _____________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________