Fellowship Application

Personal Info

Year You Are Applying For(Required)

Full Name(Required)

Birthdate(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Children (If Any)

Include Name & Age

Name

Age

Education

College/University

Date Started

Date Completed

Major Field

Degree

Honors

Graduate College/University (If applicable)

Other than Medical School

Date Started

Date Completed

Degree

Honors

Medical School

Date Started

Date Completed

Honors

Proposed Location(s) of Study & Duration of Stay

Institution (Location No. 1)

City & Country

Length of Stay

Preceptor

Institution (Location No. 2)

City & Country

Length of Stay

Preceptor

Career Plans & Reason for Seeking Fellowship

100-200 Word Statements of Career Goals etc

References

From the following:

Chief of Orthopaedic Residency Program

Name:

Email

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Two Other Academic Orthopaedic References

First Name:

Other Academic Orthopaedic References (1st)

Name:

Email

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Academic Orthopaedic References (2nd)

Name:

Email

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal Training Information

All applications and supporting letters must be received by December 1st, 2 years preceding the desired start of the Fellowship. Fellowships will normally start in August.

Orthopaedic Training

Include Place & Dates

Fellowship Training (1)

Type:

Location

Date Started

Date Completed

Fellowship Training (2)

Type:

Location

Date Started

Date Completed

Research Experience

Include Place & Dates

Other Information

Attach a separate sheet, if necessary, for the following:

Publications & Presentations as National Meeting

Max. file size: 50 MB.

Outside Interests

A copy of this completed application will be sent to both Robert T. Trousdale, MD and The Hip Society.

Questions – Please contact Dr. Trousdale at (507)284-3663 or email Trousdale.robert@mayo.edu or the Hip Society administrative office at (847)698-1638.