EFN/FADHPS/PCL Residency
Certification Form

If you choose not to submit this application electronically

 Click Here for Printable Version

 

Recipients of EFN, FADHPS and PCL scholarships with a primary care service obligation must complete this form annually during residency training to notify the school of their training activities. Recipients are also required to participate in a 3 year residency program in allopathic or osteopathic family medicine, internal medicine, pediatrics, combined medicine/pediatrics or preventive medicine approved by the Accreditation Council of Graduate Medical Education (ACGME) or by the American Osteopathic Association (AOA) or in a rotating or primary health care internship and general practice residency program approved by the AOA. * Required Fields
 

* Last Name:

    

* First Name:

    
* Year Graduated from OUCOM:      

 

* Home Address Line 1:

    

Address Line 2:

    

* City/State:

    

* Zip Code (no hyphens):

    

 

Phone Numbers:
 

* Work:

    

* Home:

    

Cell:

    

Beeper:

    
   

* E-mail Address:

    
 

* I received :

EFN

    
 

FADHPS

    
 

PCL

    
 
* and am notifying the school of my:        activities

 
* This is to certify that during the upcoming year from July 1, 2007 through June 30, 2008, I will pursue advanced professional training in
 

Family Medicine

    
 

General Pediatrics

    
 

Osteopathic General Practice

    
 

General Internal Medicine

    
 

Preventive Medicine

    
 

Other

    
 

* At (Name of Hospital):

    
 

 
Comments/Questions/Special Circumstances:  
 
I further agree to notify the school from which I received assistance immediately upon termination of my status as listed above.
 
I understand that by entering my first and last name initials (e.g.,  jb for John Brennan) in this box and submitting this application electronically, I am agreeing to all the information requested above.
 

Warning: Any person who knowingly makes a false statement or misrepresentation on this form is subject to penalties which may include fines and imprisonment under Federal Statute.
 
When you click on  submit a confirmation page containing all the information you entered above will be generated. A printed copy of the confirmation page should be retained for your own records.