Physician Assistant Postgraduate Training Program in Emergency Medicine Application

Date of Application

mm/dd/yyyy

Personal Information:

Name (Last, First, MI)

Address 1

Address 2

City

State

Zip Code

Telephone

E-mail

Educational Information:

PA School & Address

Month/Year Graduated or Anticipated

Undergraduate College Attended

Degree (1)

Month/Year Graduated (1)

College (Advanced Degree/Other)

Degree (2)

Month/Year Graduated (2)

NCCPA Certified?

If not, date of PANCE?

mm/dd/yyyy

Date Certified

mm/dd/yyyy

Certificate Number

NM Licensed?

Date Licensed

mm/dd/yyyy

License Number

References:

If you are a new graduate, please include a reference from your program director or clinical coordinator, as well as two references from preceptors (preferably in Emergency Medicine). If you are a practicing PA, please include one from your current supervising physician. Please have them email letters to Gabrielle Márquez (GaAMarquez@salud.unm.edu), or submit using this link.

All letters must be submitted by December 31st.

Name of Reference (1)

Title (1)

E-mail (1)

Address (1)

City (1)

State (1)

Zip Code (1)

Telephone (1)

Name of Reference (2)

Title (2)

E-mail (2)

Address (2)

City (2)

State (2)

Zip Code (2)

Telephone (2)

Name of Reference (3)

Title (3)

E-mail (3)

Address (3)

City (3)

State (3)

Zip Code (3)

Telephone (3)

Physician Assistant Postgraduate Training Program in Emergency Medicine Application

Personal Information:

Educational Information:

References:

Other Required Documentation: