Department of Pharmacy


	Please complete the application form and include the Following information:

	• A copy of your Curriculum Vitae • A one-page letter of intent • Three letters of recommendation • College of Pharmacy transcripts

	APPLICATION DEADLINE JANUARY 1, 2010

Name:

Address:

City:

State:

Zip:

Telephone No:

Business No:

Cell No:

College of Pharmacy:

E-mail Address:

Degree:

Graduation Date:

GPA:

Other degree(s):

I am interested in:
12 month:	PGY1 Residency
24 month:	M.S. Residency in Health-Systems Pharmacy Administration (GRE required for entrance into this program)
12 month:	PGY2 Residency Indicate area of interest:

Are you registered for the ASHP residency match? Yes No
(If so, please include your match number. Leave blank if unavailable.) Match Number:

Are you eligible for pharmacy licensure in the state of Ohio? Yes No

** Please attach a copy of your CV and a letter of intent with this submission **

Attach CV:

Attach Letter of Intent:

Please submit the application and the requested information to:

Trisha Jordan, Pharm.D., MS, Interim Director
Department of Pharmacy
The Ohio State University Medical Center
410 West Tenth Avenue, Room 368 Doan Hall
Columbus, Ohio 43210-1228
(614) 293-8470, Fax (614) 293-3165

Application for Pharmacy Residency