Physician Assistant Postgraduate Training Program in Emergency Medicine Application

Physician Assistant Postgraduate Training Program in Emergency Medicine Application

Date of Application*

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?*

Select or enter value

If not, date of PANCE?

Date Certified

Certificate Number

NM Licensed?

Select or enter value

Date Licensed

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)*

Personal Information:

Educational Information:

References:

Other Required Documentation: