MERF SCHOLARSHIP 2018 RESIDENT / FACULTY APPLICATION
Complete the information below and upload a letter from your Program Director. Deadline to submit completed applications is May 1, 2018.
FIRST NAME *
LAST NAME *
EMAIL *
YOUR MEDICAL SPECIALTY *
YOUR PROGRAM’S NAME *
PROGRAM ADDRESS *
PROGRAM CITY *
PROGRAM STATE *
PROGRAM ZIP *
HOW LONG HAVE YOU BEEN IN THIS RESIDENCY? *
FULL NAME OF PROGRAM DIRECTOR *
EMAIL ADDRESS FOR THE PROGRAM DIRECTOR: *
Upload a letter from your Program Director on institution letterhead. *
Required
YOUR MAILING ADDRESS *
MAILING CITY *
MAILING STATE *
MAILING ZIP *
PLEASE TELL US WHY YOU WOULD LIKE TO PARTICIPATE IN THIS CONFERENCE: (Maximum 300 words) *
PLEASE GIVE US YOUR SUGGESTIONS FOR HOW TO INCREASE OPPORTUNITIES FOR TRAINING ABOUT PREVENTION AND TREATMENT OF SUBSTANCE USE DISORDERS IN YOUR RESIDENCY PROGRAM. IF YOU APPLYING WITH A RESIDENT OR ANOTHER FACULTY MEMBER, EXPLAIN HOW YOU WILL WORK TOGETHER TO DO THIS. (Maximum 300 words) *
Deadline to submit complete applications is May 1, 2018.
Letter from Program Director must be uploaded in order for application to be considered.
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