CI
Application
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.
Why are you interested in becoming a Costin cohort member?
What are your goals for the program? What are the skills or topics you are most interested in learning?
What kind of position in academe do you anticipate securing upon your completion of the Costin program?
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]
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:
Completed Application form (which includes):
Demographic information
A copy of your C.V.
Answers to the questions listed under “Professional Commitment”
Two letters of recommendation
Important Dates:
Deadline: May 30, 2018
Costin Institute Dates for Cohort 15:
September 13 – 15, 2018
January 10 – 12, 2019
April 25 - 27, 2019
September 12 – 14, 2019
Questions: Call: 630-515-7421
E-mail: [email protected]
Hand-written applications will not be accepted.
M idwestern University Last Rev. 10/2017
The Chicago College of Osteopathic Medicine
2018 INTERNATIONAL SUMMER SCHOOL COURSE TEACHING APPLICATION FORM
20XX WRITTEN QUESTIONS ON APPLICATION GUIDELINES AS WE
23 DATE FEBRUARY 23RD 2009 SUBJECT APPLICATION
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