Process Improvement and Quality Initiatives Form Process Improvement and Quality Initiatives Step 1 of 3 33% Please provide the following information no later than April 1st. Externs will be selected by the committee and will be notified by the end of April. Two letters of recommendation must be received by deadline via surface mail.How would you like to be notified:* Email Mail Phone Name* First Last Email* Phone*Please include area codeAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Will this also be your mailing address?* Yes No Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender* Male Female What is your ethnicity?* Caucasian African American/Africa/Black/Caribbean Asian/Pacific Islander Caucasian Hispanic/Latino Native American Other Prefer not to answer Date of Birth* MM slash DD slash YYYY What is your citizenship?* I am a US citizen I am a US legal alien EducationTo the best of your abilities, please fill out all your education information.What is your current college classification?* Sophomore Junior What are your cumulative college hours?*What is your current overall GPA?*College Major:* College Degree:* Please list all high schools / colleges attended to date:*Press the "+" button to add more listings.School / LocationFromToDegree Supporting Documentation*Click here to upload a transcript, headshot, curriculum vitae, and other supporting documentation. Drop files here or Select files Accepted file types: pdf, doc, xls, ppt, jpg, gif, png, docx, xlsx, pptx, Max. file size: 10 MB. I certify that the information provided in this application is complete and correct to the best of my knowledge. I understand that I am responsible for having two letters of recommendation forwarded to the office of Dr. Richard Smalling no later than April 1st.* Agree Disagree Applicant Digital Signature Verification*Type your full name to certify that you agree with the above statement. We are unable to accept your application right now. Due to our minimal requirement of a 3.6 or higher GPA, we will not consider your application at this time. All other correspondence/inquiries should be directed to the following: Richard W. Smalling, M.D., Ph.D. c/o Araceli Rosas University of Texas- Houston Medical School Division of Cardiology 6431 Fannin, MSB 1.246 Houston, TX 77030 Email: Araceli.rosas@uth.tmc.edu Phone: 713-500-6559 or Fax: 713-500-6560 PhoneThis field is for validation purposes and should be left unchanged.