Professional Peer References. Please list three (3) professional peer references who have personal knowledge of your current clinical abilities, ethical character, health status, and ability to work cooperatively with others, and who will provide specific written comments on these and other relevant matters upon request. References will be evaluated according to the extent of their direct clinical observation of your work and other knowledge of you. These individuals must have acquired the requisite knowledge through observation of your professional practice over a reasonable period of time. At least one reference must be from the same specialty area, not formerly, currently or about to become associated with you in practice. At least one must be from an individual who has had organizational responsibility in a medical setting (e.g., Department Chair, Medical Director). If your training was completed within the past three (3) years, you may list your Program Director(s) as a professional reference. If you have been out of training for more than three (3) years, it is important to name individuals who are more currently familiar with your professional practice. The individuals should not be related to you by family or financial association. Reference Name 0 Xxxxx Xxxxxx Xxxxxxx Xxxx Xxxxx Zip Telephone Number Fax Number (if known) ( ) - ( ) - Relationship: (instructor, department chair, chief of staff, colleague, etc.) Reference Name 0 Xxxxx Xxxxxx Xxxxxxx Xxxx Xxxxx Zip Telephone Number Fax Number (if known) ( ) - ( ) - Relationship: (instructor, department chair, chief of staff, colleague, etc.) Reference Name 0 Xxxxx Xxxxxx Xxxxxxx Xxxx Xxxxx Zip Telephone Number Fax Number (if known) ( ) - ( ) - Relationship: (instructor, department chair, chief of staff, colleague, etc.) (Photocopy this page for additional affiliations)
