Sunday, May 11, 2008    Home | About O'Bleness | News | Services | Physicians | Health Resources | Medical Education | Calendar   Post-Doctoral Application Universal Application for Graduate Medical Education   Name Address City State Zip Code  -  find zip code Home Phone (  )    -  Cell/Pager (  )    -  E-Mail SS# AOA# ACOFP# Indicate the program to which you are applying : Traditional Internship (TI) OB/GYN Fast Track Internship Family Practice Residency (FP) Combination TI/FP OB/GYN Residency   Internship Do you have a military obligation following your internship? Yes No Branch Do you have a military obligation following your residency? Yes No Branch Do you have a public health obligation following your training? Yes No Do you have a State of Ohio medical license? Yes No License # Are you licensed to practice in another state? Yes No Location Have you ever engaged in private practice? Yes No Location Has your license been suspended? Yes No If yes, provide particular Have you ever had or been treated for Substance Abuse? Yes No If yes, provide particular   Education Background   Internship Dates To Track Institution DME Address City State Zip Code  -  find zip code   Medical Education Dates To Dean School Address City State Zip Code  -  find zip code   Graduate School Dates To Major Minor School Address City State Zip Code  -  find zip code   Undergraduate Dates To Major Minor School Address City State Zip Code  -  find zip code   Teaching Experience Institution Dates To Subject/Content Institution Dates To Subject/Content   References   Dean of Osteopathic College or Graduation Institution Address City State Zip Code  -  find zip code Telephone (  )    -    Osteopathic Physicians Physician Address City State Zip Code  -  find zip code Telephone (  )    -  Physician Address City State Zip Code  -  find zip code Telephone (  )    -    Personal Reference Name Address City State Zip Code  -  find zip code Telephone (  )    -    Release of Information I hereby authorize all hospital, medical institutions or organizations, personal physicians, employers (past & present), business and professional associates (past & present), and governmental agencies and instrumentalities (local, state, federal or foreign) to release to Ohio University - College of Osteopathic Medicine/O'Bleness Memorial Hospital, any information, files, or records required by the college/hospital for its evaluation of my professional, ethical and physical qualification for acceptance to the internship and/or residency program. I further authorize any past/present malpractice insurance carriers to release any information regarding malpractice coverage, claims pending, settled, initiated, etc. I hereby consent to the release of such information, and I hereby release from liability all representatives of the college/hospital and its medical staff for their acts performed in good faith. I hereby release from liability any and all individuals and organizations who provide information to the college/hospital, in good faith and without malice concerning my professional competence, ethics, character, malpractice insurance information, and other qualifications for acceptance to the internship and/or residency program. We consider applicants for all positions without regard to race, color, religion, gender, national origin, age, marital or veteran status. By checking this box you agree to the above terms.   Printed Name (5/11/2008)

55 Hospital Drive, Athens, OH 45701-2302 Phone: (740) 593-5551