Illinois Bone and Joint Institute

Post-Graduate Physician Assistant Orthopaedic Residency

at

Lutheran General Hospital, Park Ridge, Illinois

Directors:  Patrick Knott, PhD, PA-C   3333 Green Bay Road, North Chicago, IL  60064-3095  (847) 578-8689
                    Matthew Jimenez, MD  9000 Waukegan Road, Morton Grove, IL  (847) 375-3000
Academic Coordinator:  Christopher Webb, PA-C  (847) 375-3000
                                               
                                                To Fax Application Materials:  (847) 578-8690

New Application               Re-application   For Year:  2006  ;   2007  ;  2008  ;  2009 

Name__________________________________________________________________________________________
                                Last                                        First                                        M.I.                                         Maiden

Email Address:______________________________________________________________________________

Current Address_____________________________________________________________________________
                                                Street                                                                      City

                                ____________________________________________________________________________
                                                State                       Zip Code                                Phone

Permanent Address___________________________________________________________________________
                                                Street                                                                      City

                                ____________________________________________________________________________
                                                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 _____________

Graduate College_________________________________________________________________________ 

Degree Obtained___________________  Major_____________________ Graduation Year _____________

Page 2.  Illinois Bone and Joint Institute       Application for Post-Graduate Residency

Are you currently NCCPA Certified? No     Yes     If not, when do you plan to take the test: _______________

 Do you currently hold a PA license in any state?  No     Yes   ________________________
                                                                                                                                State(s)

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 list at least two persons who will be sending letters of recommendation on your behalf.  (Note, one must be from your PA Program Director)

____________________________________________PA Program Director__________________________________
                Name                                                                                      Title                                        Daytime Phone Number

_______________________________________________________________________________________________
                Name                                                                                      Title                                        Daytime Phone Number

_______________________________________________________________________________________________
                Name                                                                                      Title                                        Daytime Phone Number

Resume:  Please attach your resume to this application.

Personal Statement:

Please attach a one-page essay explaining why you are applying, what you expect from a post-graduate residency program, and how your PA Program prepared you for this challenge.

I certify that the information in this application is complete and correct to the best of my knowledge and belief.

________________________________________________                                ______________________________
                                 Signature                                                                                                          Date

It is the policy of the Illinois Bone and Joint Institute not to discriminate on the basis of race, gender, religion, sexual orientation, or handicap in admissions or in employment.  It is the Institute’s intent to comply with all applicable statutes and regulations.