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St. Joseph Mercy Hospital
Cardiothoracic PA Residency Program
Michigan Heart & Vascular Institute
5325 Elliott Drive, Suite 102
Ypsilanti, MI 48197
Program Application Instructions
If downloading this application, you may hit "Print" on your web browser to print
this page. You may then fill out the application by hand. If you wish to complete
the application on your computer, "Save" this page as a text document, then open it
using your word processor. You may then type your answers to the questions.
Notify the residency program of your intention to apply by sending an e-mail message
to djones@ctpa2b.com
1. Submit the completed application form and fee, personal statement and curriculum
vitae to the above address, Attn: Diane J. Jones.
There is a non-refundable $25.00 application fee. A check made payable to St.
Joseph Mercy Hospital should accompany your application form.
2. Have three letters of recommendation sent to the residency program. One letter must
be from your Program Director. The letters should be addressed to Andrew Pruitt, MD and mailed directly to him at the above address.
3. Have your PA Program send official transcripts to Diane J. Jones at the above address.
Transcripts from educational programs other than PA school are not necessary.
4. When your application is received you will be sent a letter of acknowledgement.
Application Checklist
1. Application
2. Application Fee
3. Passport Photo
4. Personal Statement
5. Curriculum Vitae
6. Recommendation Letters
7. Transcripts
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St. Joseph Mercy Hospital
Physician Assistant Residency
in Cardiothoracic Surgery
Send application to:
Diane J. Jones, PA-C
Michigan Heart & Vascular Institute
5325 Elliott Drive, Suite 102
Ypsilanti, MI 48197Attach Photo
__New Application __Re-application Here
For Month:__July__January
For Year:__2002 __2003 __2004 __2005
Name:
______________________________________________________________________
Last First M.I. Maiden
Social Security Number:__________________ E-mail Address:________________
Current Address:
______________________________________________________________________
StreetCity
______________________________________________________________________
State Zip Code Phone
Permanent Address:
______________________________________________________________________
StreetCity
______________________________________________________________________
State Zip Code Phone
Date of Birth_____________ Gender: __Male __Female
PA Program Attended (Attending):_________________________________________
Graduation:_____________ Degree:________________________________________
Month/Yr.
Undergraduate College _________________________________________________
Degree Obtained_______________ Major_______________ Graduation Year_______
Undergraduate College _________________________________________________
Degree Obtained_______________ Major_______________ Graduation Year_______
Undergraduate College _________________________________________________
Degree Obtained_______________ Major_______________ Graduation Year_______
Page 2. St. Joseph Mercy Hospital
Application for Post-Graduate Residency
Do you currently hold a PA license in any state? No__ Yes__ State(s)______________
Please list past medical experience, either as employment or as a volunteer:
______________________________________________________________________
Position Location Dates
______________________________________________________________________
Position Location Dates
______________________________________________________________________
Position Location Dates
______________________________________________________________________
Position Location Dates
Were you ever required to leave any college, graduate or professional school or ever
denied readmission because of deficiencies in either conduct or scholarship?
__No __Yes (Explain below)
______________________________________________________________________
______________________________________________________________________
Have you ever been convicted of a felony in any state, or had a professional license
revoked? __No __Yes
Letters of Recommendation
Please provide the names of three people who will be sending recommendation letters
on your behalf. (Note, one must be your PA Program Director.)
______________________________________________________________________
Name Title Daytime Phone Number
______________________________________________________________________
Name Title Daytime Phone Number
______________________________________________________________________
Name Title Daytime Phone Number
Personal Statement
Please attach a one-page essay describing your career goals and source of interest
in cardiothoracic surgery.
I certify that the information in this application is complete and correct to the best
of my knowledge and belief.
______________________________________________________________________
SignatureDate
It is the policy of the Residency Program not to discriminate on the basis of race,
gender, religion, sexual orientation, or handicap in admissions or employment.
It is the Program's intent to comply with all applicable statutes and regulations.
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