Application For Preventive Medicine Residency Program (Pmrp) Page 2
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2Name: ________________________________________________
17. Membership in professional or honorary associations:
18.
Honors, prizes, awards:
19.
Publications:
REFERENCES. Request that three persons, including at least one physician, send a letter of recommendation to the Program at
20.
the address below. List your references here:
Name
Occupation and Title
Institution /Telephone/E-mail
(1)
(2)
(3)
STATEMENT OF PURPOSE: Please attach one typed page giving your reasons for wanting to undertake training provided by
21.
this preventive medicine residency program. THE PREVENTIVE MEDICINE RESIDENCY ADVISORY COMMITTEE OF THE
CALIFORNIA DEPARTMENT OF PUBLIC HEALTH CONSIDERS THIS TO BE A CRUCIAL PART OF YOUR APPLICATION.
Include your future professional plans and any other information which may be helpful to the Committee.
Note: An interview is required before a final decision can be made. After your application has been reviewed, we will notify you if
22.
you are eligible for an interview.
NOTICE TO APPLICANTS:
The information requested on this form is required by the State Department of Public Health in order to determine your eligibility for
acceptance into the Department’s Preventive Medicine Residency Program. The information will also be used by the Department’s
Preventive Medicine Advisory Committee to select candidates for inclusion into the residency training program. Participation in this
residency program is voluntary. If you choose to participate, you are required to provide information on these forms. If you do not
provide this information, admission into the residency program may be denied.
Any information that you provide may be used by the State Department of Public Health or transferred to the Department of Public
Health's Preventive Medicine Advisory Committee and institutions formally participating in the residency training program. Candidates
and authorized personnel directly involved in the selection process will be allowed access. If you wish to review these records, contact
Kathleen H. Acree, M.D., M.P.H., at the address below. After reviewing your records, you may request in writing that they be corrected or
amended to make them accurate, relevant, and complete. Any request for correction or amendment should also be sent to Dr. Acree.
I certify that the information I have provided in my application is correct, and that I have read the above “Notice to Applicants.”
________________________________________
___________________
Signature
Date
Please mail this application form with any attachments to:
For FedEx, UPS, or other courier:
Program Coordinator
Program Coordinator
Preventive Medicine Residency Program
Preventive Medicine Residency Program
California Department of Public Health
California Department of Public Health
MS-7213
MS-7213
P.O. Box 997377
1616 Capitol Avenue, Suite 74.420
Sacramento, CA 95899-7377
Sacramento, CA 95814
In addition, please have official transcripts and letters of recommendation mailed directly to the appropriate address above. If you have
any questions, please telephone the Program Coordinator at (916) 552-9920 or e-mail CDPH-PDS@cdph.ca.gov. Thank you.
Page 2 of 2
CDPH 8565 (05/07)
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