FAMILY NAME, GIVEN NAME, DATE OF BIRTH, NATIONALITY: PERMANENT HOME ADDRESS, HOME PHONE NUMBER: NAME, ADDRESS, TELEPHONE, AND FAX OF UNIVERSITY/HOSPITAL: PRESENT POSITION: HEAD OF DEPARTMENT: LANGUAGES SPOKEN: PLEASE SELECT ONE OF THE FOLLOWING: ENGLISH SPANISH FRENCH GERMAN OTHER
Medical Studies: NAME AND ADDRESS OF SCHOOL, DURATION, DATE OF GRADUATION: Post Graduate Education: LOCATION, DURATION, AND QUALIFICATION OF GENERAL SURGERY: LOCATION, DURATION, AND QUALIFICATION OF ORTHOP. SURGERY: DETAILS ABOUT SPECIAL TRAINING IN TRAUMA: (shock, polytrauma, hand injuries, closed and open treatment of fractures, etc.) DO YOU UTILIZE ORIGINAL AO ASIF INSTRUMENTS & IMPLANTS: YES NO ARE YOU RESEARCH ORIENTED: YES NO IN WHICH AREAS: ARE YOU CURRENTLY ACTIVE IN RESEARCH: YES NO CLINICALLY, EXPERIMENTALLY, PLEASE EXPLAIN: PUBLICATIONS: YES NO (please attach or send your bibliography) IN WHICH FIELDS ARE YOU INTERESTED: (Trauma, hand surgery, maxillofacial, spine, others) WHERE AND WHEN DID YOU TAKE THE AO BASIC AND ADVANCED COURSES: ARE YOU AN AO FACULTY MEMBER: YES NO ARE YOU AN AO NORTH AMERICA MEMBER: YES NO WHAT DO YOU EXPECT FROM YOUR JACK MCDANIEL FELLOWSHIP EXPERIENCE, WHERE AND WHEN WOULD YOU LIKE TO GO TO TAKE IT, AND WITH WHOM: PLEASE ENCLOSE THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION: 1) MINIMUM OF TWO LETTERS OF RECOMMENDATION 2) CURRICULUM VITAE 3) LIST OF PUBLICATIONS AND/OR LECTURES 4) TWO PHOTOGRAPHS PLEASE SEND COMPLETED FORM TO: