Application For Preventive Medicine Residency Program (Pmrp)
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1
2State of California – Health and Human Services Agency
California Department of Public Health
APPLICATION FOR PREVENTIVE MEDICINE RESIDENCY PROGRAM (PMRP)
Please PRINT OR TYPE all responses, then sign and date on the next page. In addition, attach a typewritten Statement of Purpose (see item 22). For items 16-21, if your
curriculum vitae (C.V.) contains the requested information, attach your C.V. and write “see attached C.V.” in the blank space(s).
1.
Name:
Last
First
Middle
2.
Address (street, city, state, ZIP)
3.
Telephone
Work: (
)
Home: (
)
4.
Birth date
5.
Are you a U.S. citizen?
6.
If non-U.S. citizen, specify citizenship and type of
Email:
visa.
Yes
7.
Legal Resident of California?
___________________________
Month
Day
Year
No
Yes
No
8.
Are you licensed to practice medicine in California?
(REQUIREMENT)
9.
In what other states are you licensed? (Include license number and expiration)
Yes
No
If Yes: License Number: _________________
Expiration: _____________
10.
If you are certified by a specialty board:
indicate specialty:___________________________________________________
date of certification:________________________________________
and certificate number:___________________________
11.
Please rate the following possible geographic locations for your residency placement using the following scale:
0=not acceptable, 1=acceptable but not preferred, 2=preferred
Southern CA ___
Central Valley ___
S. F. Bay Area ___
Sacramento Area ___
Northern CA ___
12.
Applying for:
13.
If academic year, also applying to:
14.
Are you applying for a residency stipend?
Academic & Practicum
UC Berkeley
UCLA
UC Davis
Yes
No
Practicum Year Only
EDUCATION, INTERNSHIPS, RESIDENCIES. Have official transcripts of your graduate (post-baccalaureate) education mailed
15.
to the program at the address on the next page. Summarize your undergraduate education, graduate education, internships, and
residencies here. Attach additional pages or a C.V. if necessary
.
Diploma or
Date of
Names and Locations of Schools or Institutions Attended
When Matriculated
Major
Degree
Completions
EXPERIENCE RECORD: List chronologically all experience in medicine, public health, or related fields excluding internship and
16.
residencies (but including periods of private practice and military service). The earliest employment should appear first. Attach
additional pages or a C.V. if necessary.
Dates
Name and Address (City, State) of Employer
Description of Duties or Position
From
To
Page 1 of 2
CDPH 8565 (5/07)
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