Clinical Cardiology Electrophysiology
Fellowship Application

Instructions:  This application is for the two CCEP Fellowships which begin in July, 2010.  The application deadline is April 1, 2009.  We will conduct interviews in May and June.

  1. Please complete this application form and submit. 

  2. You may email (cee2j@virginia.edu) or mail (see below) your curriculum vitae and your personal statement to Cynthia Elledge-Volker, PhD, Program Administrator for the Clinical Electrophysiology Fellowship Program.

  3. Please submit two letters of recommendation addressed to Michael Mangrum, MD, Director of Clinical Cardiac Electrophysiology. One letter must come from your Cardiovascular or Cardiology Fellowship Program Director, and another from the Division Chief of Cardiology at your present institution. Additional letters of reference are welcome. 

    Mail or FedEx to:

Michael Mangrum, MD
c/o Cynthia Elledge-Volker, PhD
CCEP Fellowship Education Administrator
Cardiovascular Fellowship Program
1215 Lee Street Room 2772
PO Box 800662
Charlottesville, VA 22908
(434) 924-9001

We also accept faxed letters at: 434-244-7581

For more information, please contact Cynthia Elledge-Volker, PhD, Program Administrator, at (434) 924-9001 or email at cee2j@virginia.edu.

Personal
  Last Name,                          First Name                     Middle Initial
  ,
  Email Address
 
  Home Address
 
  City                            State                           Zip
 
  Phone                        FAX
 
  Work Street Address
 
  City                            State                          Zip
 
  Phone                        FAX
 
  Visa Status (If Applicable)
 
Education
  Premedical College Degree, Date (mm/yyyy)
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  Medical College Degree, Date (mm/yyyy)
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  Internship Location and Dates
 
  Residency Location and Dates
 
  Fellowship Location and Dates
 
Additional Information
  Previous Military Service & PHS or Military Obligations:
 
  Honors, Awards, Organizations:
 
  Research or Related Activities:
 
  Publications:
 
  Future Career Plans: