Fellowship Application

Personal Information

Name (Last, First, Middle Initial)

Address

City

State

Zip

Home Phone

Cell Phone (if applicable)

Email Address

Date of Birth

Gender

Name of Spouse

Names of Children

College Information

College

Degree

Dates Attended

City and State

Medical School Information

Medical School

Degree

Dates Attended

City and State

Residency Information

Residency

Degree

Dates Attended

City and State

Type of Training

Training

Location

Degree

Dates Attended

City and State

Type of Training

Pastoral Information

Name and address of your church and pastor

Spiritual Information

Please tell us about your relationship with God

Proposed Medical Missions Work

Name of Hospital or Location

Address

Name of affiliated church or missions organization

Intended Dates of Service

Identify the goals of your proposed mission trip

Identify the specific expenses for your proposed mission trip

References

Please list the names and titles of three references who will send letters of recommendation. One letter should be from your pastor or a similar person who can address your spiritual interests. The other two should be from people who can address your academic or clinical qualifications. Your references should mail or fax these letters directly to Southwestern Medical Clinic.

Name and Title of Reference 1

Name and Title of Reference 2

Name and Title of Reference 3

Application Deadline

This application is for a deadline of

Certification

I certify that the information in and attached to this application is accurate to the best of my knowledge and agree to the terms and conditions of the fellowship as described in the application.

Signed (Type Name)

Date

Security Code

Security Code :: Type in the five character security code that you see to the right of the input box.