President: Herbert Silverstein, MD, FACS

Vice President: Seth Rosenberg, MD, FACS

Director of Research: Jack Wazen, MD, FACS

Name: _____________________________________ Social Security #: ___________________

Address: ______________________________________ Phone: (____)____________________

City: ___________________ State: _______ Zip: _______________ Country: ______________

Office Address: ________________________________ Phone: (____)_____________________

City: _____________________State: _______Zip: _______________ Country: _____________

Date of Birth: _________________ Place of Birth: ____________________________________

Medical School: ________________________________________________________________

Internship: Hospital___________________________ Year: ________ Services: _____________

Any special otology training Yes _________ No ________ (if yes, where) ___________________

What are your future career plans ( Attach separate sheet if necessary)

1. ________ Military Service Location _________________________________________________

2. ________ Academic Location ______________________________________________________

3. ________ Clinic Practice Location ___________________________________________________

4. ________ Academic & Clinic Practice Location _________________________________________

5. ________ Research Location _______________________________________________________

Do you have a Florida License Yes ______ No ______ (If yes indicate #) _______________________

If no, do you have reciprocity with your state: Yes ______ No ______

If no, can you apply for a Florida License      Yes ______ No ______

Available to begin a 12 Month Fellowship on: Day __________ Month ___________ Year ___________

Are you in good health Yes _____ No _____ (If no explain) __________________________________

Applicant’s Signature ____________________________________ Date: ______________________

Please include the following with your application: