Graduate Training Program in Emergency Medicine

Phone:

Do you have the legal right to work in the United States?

For Primary Care Physicians Fax: 937-312-3470 koganowski@phcsday.com ***Cell Phone: 937-469-4773Premier Health Care ServicesPlease mail, fax, or email these documents to:Kas Oganowski, MD Associate Director of Premier Graduate Training ProgramPremier Health Care ServicesDesk Phone: 937-312-3468 or 800-726-3627 (x3468).....For More Information Contact:(500 character max.)(500 character max.)(500 character max.)(500 character max.)(xxxyyyzzzz)(xxxyyyzzzz)Electronic SignatureAuthorizationHonors/Awards:Date Entered:Graduation Date:////Phone:Zip:State:City:Address:Name:If yes, please list:Have you participated in any other residency programs?Honors/Awards:If no, why?Are you Board Certified/Eligible?Graduation Date:Date Entered:Program Director's Name:///Residency ProgramEmail:Zip:State:City:Address:Last Name:First Name:Applicant Information
Phone:Zip:State:City:Address:Name:/
Medical School
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, incomplete, false, or misleading statements on this application shall be grounds for dismissal at any time in the future.I authorize investigation of all statements contained herein and any personnel listed above to give you all information concerning my previous employment and education along with any pertinent information they may have, personal or otherwise, and release all parties from liability for any damage that may result from furnishing same to you.Date:8/21/2008 5:54:06 PM
(xxxyyyzzzz)
Kas Oganowski, MDkoganowski@phcsday.com332 Congress Park Dr., Dayton OH 45459
Other Requirements to complete the application process:Photo3 Letters of RecommendationOne must be from your Program DirectorPersonal StatementMust include why you are pursuing further training in Emergency MedicineCVUSMLE Transcript, if applicableECFMG Status Report, if applicable.Associate Director, Graduate Training Program 332 Congress Park DriveDayton, OH 45459 *** Click here for a downloadable version to mail or fax Fax: 937-312-3470