Certification Of Medical Education For printable pdf download

Certification Of Medical Education For

Medical Staff Services

2500 Green Rd., Ste. 700

Ann Arbor, Michigan 48105-1597

Telephone: (734) 647-6865 Fax (734) 936-9757

CERTIFICATION OF MEDICAL EDUCATION FOR

MEDICAL SCHOOL GRADUATES

Instructions: Applicant complete Section I. Type or print your name exactly as it appears on

your application. Send this application to the Dean of the Medical School you attended (Section

II). The Dean of the Medical School will complete this information and mail it directly to

Medical Staff Services, University of Michigan Hospitals and Health Centers.

IMPORTANT

THIS FORM MUST BE RECEIVED IN THE MEDICAL STAFF

SERVICES OFFICE AT THE UNIVERSITY OF MICHIGAN

HOSPITALS AND HEALTH CENTERS FOR YOUR

APPLICATION PACKET TO BE CONSIDERED COMPLETE.

SECTION I - APPLICANT INFORMATION

Applicant’s Name (Last, First, Middle)

Street Address

City

State

ZIP Code

Social Security Number

Date of Admission

I will be working in the Department of __________________________________________________.

I hereby release from liability all individuals and organizations who provide information concerning my

qualifications for staff appointment and clinical privileges.

Signature of Applicant _______________________________________Date__________________________

Applicant: Upon completion of Section I, send this form to the Dean of your medical

school for completion of Section II on the reverse side of this form.

Version 1-2-08

Certification Of Medical Education For