PA Fellowship Application

First

Last

Address

City/Town

State/Province

ZIP/Postal Code

Phone number

For which fellowship are you applying?

Emergency Medicine

Primary Care

Neurology

You are only eligible to apply to one specialty track.

Education

What school are you attending?

Address

City/Town

State/Province

ZIP/Postal Code

Country

What is your anticipated graduation year and month?

Please indicate your GPA.

Have you taken and passed the PANCE?

Yes

If no, when are you scheduled to take PANCE?

Do you currently have, or will you have your Virginia PA License at least 6 weeks before orientation?

Yes

Do you currently have, or will you have your DEA License at least 6 weeks before orientation?

Yes

Statement of interest

Please state why you are interested in postgraduate fellowship training in the specialty for which you are applying.

Please, no more than 500 words.

Letters of recommendation

The application requires two (2) professional letters of recommendation. These letters must be emailed directly from the writer’s professional email account to morgan.mcdowell@centrahealth.com or can be sent in a sealed envelope directly from the writer to:

Office of Medical Education & Student Affairs (OMESA)
PA Fellowships
Attn: Morgan McDowell, DNP
1901 Thomson Drive
Lynchburg, VA 24501

Reference #1

Title

First

Last

Phone number

Relationship to applicant.

Reference #2

Title

First

Last

Phone number

Relationship to applicant.

Check one

I hereby waive access to the above mentioned letters and will so inform the authors.

I desire access to the above mentioned letters and will so inform the authors.

Support documentation needed:

Please submit the following documents as pdf files only to morgan.mcdowell@centrahealth.com. If you are local, please feel free to deliver in person to the OMESA building at 1901 Thomson Drive.

Curriculum vitae
Unofficial graduate transcripts

I certify that the information submitted on these application materials is complete and correct to the best of my knowledge. I understand that any false or missing information may disqualify me for this position.

Applicant e-Signature

Date of signature