Dept. of Ophthalmology

Anterior segment, Cornea, and Refractive surgery:

M. Bowes Hamill, M.D.

Douglas D. Koch, M.D.

Stephen C. Pfulgfelder, M.D.

Mitchell P. Weikert, M.D.

Diseases and surgery of the retina and vitreous:

Alice McPherson, MD
Eric R. Holz, MD

Pediatric Ophthalmology and Strabismus:

David K. Coats, MD
Jane C. Edmond, MD
Evelyn A. Paysse, MD
Kimberly Yen, MD

If applicable, are you registered with the National Fellowship Matching Program?: yes Number:
First Name:
Middle Initial:
Last Name:
Email Address:

Address:
Street:
City:
State:
Zip:
Country:
Home Phone Number:
School or Hospital Phone Number:

Address Cont.:
Birthdate:
U.S. Citizen?:
If non-citizen, date of entry into U.S.:
If non-citizen, type of Visa held:

For Foreign Students:
If a graduate of a foreign medical school, have you obtained certification from the Educational Commission for Foreign Medical Graduates? yes
Indicate exams passed:
ECFMG:
Visa Qualifying Examination:
FMGEMS:
National Board Exam:
U.S. Medical Licensing Exam:
FLEX:

Internship, Residency, and/or Fellowship:
Hospital Name:
Address:
From: To:
Field:

Hospital Name:
Address:
From: To:
Field:

Internship, Residency, and/or Fellowship Cont.:
Hospital Name:
Address:
From: To:
Field:

Hospital Name:
Address:
From: To:
Field:

Internship, Residency, and/or Fellowship Cont.:
Graduate School:
Address:
From: To:
Degree(s):

Internship, Residency, and/or Fellowship Cont.:
Membership in Honorary or Professional Societies, prizes, awards, fellowships, etc. Please include AOA membership.

Internship, Residency, and/or Fellowship Cont.:
Professional Goals and Career Plans

U.S. Board Certification or Eligibility:
Specialty:
Certified? Eligible?
Date of Certification:

Specialty:
Certified? Eligible?
Date of Certification:

Practice or other clinical experiences:
Location:
From: To:
Type:

Location:
From: To:
Type:

References:
Please list four (4) references. Your references must include a letter from the Director of Residency Training of your residency program, and two physicians who can render an evaluation of your professional and academic abilities. Please ask that your recommenders comment on academic and personal attributes such as judgment, industry, interpersonal relationships, capacity to assume responsibility and professional ethics.
Chairman or Director:
Address: