NEW JERSEY MEDICAL SCHOOL

THE INSTITUTE OF OPHTHALMOLOGY AND VISUAL SCIENCE

 
PLEASE NOTE THAT THIS IS NOT AN INTERACTIVE FORM.
  • PLEASE PRINT AND FILL OUT THIS FORM TO APPLY FOR THE PROGRAM.
  • COMPLETE ALL INFORMATION INCLUDING YOUR GRADUATION DATES AND YOUR CURRENT OPHTHALMIC SKILLS (eg, history taking, visual acuity, lensometry, etc.)
  • ASK YOUR SPONSORING OPHTHALMOLOGIST TO SIGN THE FORM BEFORE YOU RETURN IT.
INSTITUTE OF OPHTHALMOLOGY AND VISUAL SCIENCE
UMDNJ-NEW JERSEY MEDICAL SCHOOL

OPHTHALMIC MEDICAL ASSISTANT PROGRAM (OMAP)

OMAP APPLICATION FORM (Please print clearly or type)

DATE
(Month/Day/Year):
     
NAME
(Last)(First)(MI):
     
HOME ADDRESS
(Street):

(City)(State)(Zip Code):
 
     
DATE OF BIRTH
(Month/Day/Year):
     
  TELEPHONE
(Area Code) (Number)
   
         
SIGNATURE OF
APPLICANT 		 
 
.............................................................................................................................
EDUCATIONAL BACKGROUND
High School: Name:
Address:
Major:
Year of Graduation: Diploma:
College: Name:
Address:
Major:
Year of Graduation: Diploma:
Other School: Name:
Address:
Major:
Year of Graduation: Diploma:
   
NUMBER OF YEARS IN OPHTHALMIC FIELD:
 
 
CURRENT OPHTHALMIC SKILLS (List each):
 
COURSES TAKEN IN OPHTHALMOLOGY (Detailed description):
 
............................................................................................................................
EMPLOYER
NAME:
 
ADDRESS (Street):

(City)(State)(Zip Code):
 
     
TELEPHONE NO:
   
   
  SIGNATURE OF
SPONSORING
OPHTHALMOLOGIST 		 
 

 

 

 

 

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