The following information will be used in the introductory paragraphs of your dean's letter. 

1. NAME___________________________________________________ 

BIRTH PLACE_____________ 

BIRTHDATE_______________ 

2. UNDERGRADUATE INSTITUTION______________________________ 

MAJOR, DEGREE & DATE___________________________________ 

3. GRADUATE EDUCATION_____________________________________ 

MAJOR, DEGREE & DATE___________________________________ 

4. MATRICULATED IN THE SCHOOL OF MEDICINE_________________ 

5. AWARDS in undergraduate and/or graduate school that you would like included in your Dean 's Letter
_______________________________________________________ _______________________________________________________ _______________________________________________________ 

6. DISINGUISHED ACTIVITIES BEFORE MATRICULATING IN THE SOM THAT YOU WOULD LIKE INCLUDED 
_______________________________________________________ _______________________________________________________ _______________________________________________________ 

7. EXTRACURRICULAR ACTIVITIES WHILE IN THE SOM (SOM committees, DOC, Doctor for a Day, etc.)
_______________________________________________________ _______________________________________________________ _______________________________________________________ 

8. HAVE YOU PUBLISHED OR PRESENTED YOUR WORK WHILE A STUDENT AT UCSD? (Attach additional sheets with complete information. 

9. IS THERE ANYTHING ELSE THAT YOU WOULD LIKE INCLUDED THAT ISN'T MENTIONED ABOVE?_____________________________________________ _____________________________________________________________ 

APPENDIX B (2 OF 2) DEAN'S LETTER INFORMATION SHEET
FORM B DUE: mid-July 

1. CHOICE(S) OF SPECIALTY FOR RESIDENCY TRAINING (PGY 1 AND 2) APPLICATION: 

_______________________________________________________ _______________________________________________________ 

2. PLANS AFTER RESIDENCY TRAINING: (fellowship, academic medicine, private practice, HMO, etc.) 

_______________________________________________________ _______________________________________________________ 

3. FACULTY ADVISOR: (Person who will review the draft of your dean's letter) 

_______________________________________________________
Please print name, department, phone number and mail code 

4. INDEPENDENT STUDY PROJECT (ISP): Brief description 

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 

5. ATTACH A COPY OF YOUR CURRICULUM VITAE AND PERSONAL STATEMENT TO THIS FORM. 

6. PRINT YOUR NAME AS IT SHOULD APPEAR ON YOUR MEDICAL SCHOOL DIPLOMA: 

_______________________________________________________ 

YOU MUST SUBMIT A LIST OF NAMES AND ADDRESSES OF THE RESIDENCY PROGRAMS AND ADDRESSED ENVELOPES TO THE OFFICE OF STUDENT AFFAIRS IF THE SPECIALTY YOU HAVE CHOSEN DOES NOT USE THE ELECTRONIC RESIDENCY APPLICATION SERVICE (ERAS). ENVELOPES WILL BE PROVIDED BY THE OFFICE OF STUDENT AFFAIRS.