Application Form for Fellowship in Primary Care Sport Medicine at The Fowler Kennedy Sport Medicine Clinic

Name: ____________________________________________________________

Address: __________________________________________________________

Postal Code: ___________________

Telephone: Residence:(_____)_______________Work:(_____)_______________

The following items are required:

• A letter outlining the request for Fellowship status.
• Three letters of reference forwarded to: Director of Primary Care, The Fowler Kennedy Sport Medicine Clinic
• Up to date Curriculum Vitae
• Copy of Transcripts

All applicants should forward the above items to:

The University of Western Ontario,
London, Ontario N6A 3K7,
Tel:519-661-3011,
Fax:519-661-3379