CI APPLICATION 3 APPLICATION FOR ADMISSION 20182019 NAME 

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The Costin Institute for Medical Educators

CI Application 3


CI APPLICATION 3 APPLICATION FOR ADMISSION 20182019 NAME 



Application for Admission

2018-2019


Name:     

Home Address:      

     

Home Phone:      

Business Address:      

     

E-mail:      


Preferred Mailing Address: Home Business

Preferred means of contacting you: E-Mail Other _____________

Is there anyone else (i.e. your assistant) who should be included on all correspondence? If so please specify name and email

     ________________________________________________________________________

Birthdate:     

Gender: Male Female

Citizenship: U.S. Other _______________________________


Ethnic Background: African-American/Black Hispanic/Latino

(Optional) Asian/Pacific Islander Native American

Caucasian/White Multi-Racial


Other ___________________

MWU/CCOM Affiliation (please specify):      


II. Professional Information:

Please attach a copy of your curriculum vitae.

III. Interest in the Costin Institute

Please answer the following questions. You may attach a separate sheet with your responses.

  1. Why are you interested in becoming a Costin cohort member?

     

  1. What are your goals for the program? What are the skills or topics you are most interested in learning?

     

  1. What kind of position in academe do you anticipate securing upon your completion of the Costin program?

     

  1. Is there anything else you would like the Admission Committee to know about you?

     

IV. Letters of Recommendation:

Please submit two letters of recommendation.


The letters should address your commitment and achievements in medical education. Please submit letters to:


Costin Institute

CI Application

CCOM/MWU

555 31st Street

Downers Grove, IL 60515

- or -

E-mail to: [email protected]


CI APPLICATION 3 APPLICATION FOR ADMISSION 20182019 NAME 


Application for the Costin Institute




Instruction Sheet

(Keep for your records)

Hand-written applications will not be accepted.



The following items are required for a completed application to the Costin Institute:


  1. Completed Application form (which includes):

    1. Demographic information

    2. A copy of your C.V.

    3. Answers to the questions listed under “Professional Commitment”

  2. Two letters of recommendation



Important Dates:


Deadline: May 30, 2018


Costin Institute Dates for Cohort 15:





Questions: Call: 630-515-7421

E-mail: [email protected]

Web: www.costininstitute.org


Hand-written applications will not be accepted.

MCI APPLICATION 3 APPLICATION FOR ADMISSION 20182019 NAME  idwestern University Last Rev. 10/2017

The Chicago College of Osteopathic Medicine


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