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4Continue
to cover letter
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Name:
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Employee
ID Number: |
Program
Deadline Date (e.g. May 1st): |
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| Instructions:
Please print, complete and submit this form with your application.
Please note that incomplete applications will result in delayed
processing of your portfolio. |
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Guidelines
for Application Checklist
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- We
will confirm receipt of your application and notify you of your
scheduled interview date via your partners.org email address. Please check your account regularly
for information.
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Note: Please ensure that
your name, employee ID number, and program deadline date for which
your are submitting your application (e.g. May 1st) are
indicated in the top left hand corner of each document you submit. |
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Please
indicate
the level of practice for which you are applying:____________________ |
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Please
indicate
your current level of practice:__________________________________
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Please place an ‘X’ here if this is your first time submitting
an application to the Clinical Recognition Program
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Please
check that you have submitted all contents of your application.
All application materials must be typed (except for the Application
Checklist). Place an
‘X’ next to each item submitted: |
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| __ Completed and signed checklist (may be handwritten) |
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Cover letter
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__ Clinical Narrative (occurring within the past six months) |
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| __ Resume/Curriculum Vitae |
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Endorsement from your manager/director (if you practice in more than one area, managers from all practice areas must sign form):
Name of manager director: ________________________
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First letter of support from within
your discipline:
Name of your colleague: ___________________________
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Second letter of support from within
your discipline:
Name of your colleague: ___________________________
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First letter of support from outside
of your discipline:
Name of your colleague: ___________________________
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Second letter of support from outside
of your discipline (Clinical Scholar only):
Name of your colleague: ___________________________
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Signature of applicant:
Date:
_________________________________
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All
portfolios become the property of the Clinical Recognition Program.
Please keep a copy for your records |
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