APA Public Psychiatry Fellowship
1. Name: (First, Middle, Last)  
2. Home Address:  
    Home Phone:  
    Home Email:  
    Work Address:  
    Work Phone:  
    Work Email:  
3. Are you currently a member of the American Psychiatric Association?
If YES, (if known) please enter Membership number:
4. If NO, are you in the process of becoming an APA member?
EDUCATIONAL BACKGROUND:

5. Pre-medical education (name/location of college, years attended, degree received, major):
Name  
Location  
Dates  
Degree  
Major  
6. Medical Education (name/location of medical schools, years attended, year MD/DO degree received):

Name  
Location  
Dates  
Degree  
7. Internship (indicate if internship was separate from or combined with first year of residency):
Name  
Location  
Degree  
8. Residency Training:

Name  
Location  
9. PGY Level:

Current Level:  
Current Residency Year Began:  
PGY Level as of May 2016:  


10. Indicate any other medical training or experience:

 
11. Indicate area(s) of special interest in psychiatry:

 
12. List honors, awards, recognition (e.g. scholastic, career, public service):

 
13. List prior employment:

 
14(a). College public service and/or volunteer activities:

 
14(b). Medical School public service and/or volunteer activities:

 
14(c). Residency public service and/or volunteer activities:

 
15. Describe your primary extracurricular activities in a few sentences:

 
6. Briefly describe any research experience you have had (e.g., thesis):

 
17. List any published original works, giving dates and sources:

 
18. List any organizational memberships or affiliations:

 
19. What are your plans as a participant in the public service sector after completion of your current training?

 
20. Other personal attributes or experiences that you believe might distinguish you from other candidates:

 
ESSAY:

21. Write an essay, not to exceed two single-spaced pages, proposing how the fellowship would be utilized to enhance your present training and ultimately assist you in achieving your career goals.