2022 Chris O'Brien Traveling Fellowship Award Application - Research and Education Foundation of the American Head and Neck Society

Step 1 of 2

A current, detailed curriculum vitae, including medical school, postdoctoral education, and past hospital appointments, plus a complete bibliography and record of meeting presentations are to be submitted with this application. Applicants are to submit, in addition, an essay of no more than one page, stating how, in their opinion, they fulfill the requirements and their reasons for applying for the fellowship. Applicants are requested to indicate their name in the upper left-hand corner of the essay.

1. Applicant

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Present Academic Position

Title

Institution

Birth Date

Birth Place

Citizenship

2. Education

Senior (Chief) Residency

Year

Institution

Address

City State / Province / Region

3. Present Hospital Appointments

Name of Hospital

Address

City State / Province / Region

Surgical Staff Position

From (specify month and year)

Other:

4. Specialty Certification Designation

American Specialty Board/ The Royal College of Physicians and Surgeons of Canada

Name of Specialty (Board)

Date of Specialty Certification

Name of additional specialty (board) if applicable

Date of additional specialty certification

5. Fellowship

ACS

Date Awarded

RCSC

Date Awarded

6. References

Three letters of reference are required. One should be from the department chair, and the other two, from active members of the surgical department. These letters should include an overall evaluation of the applicant, including assessment of the applicant’s performance in various positions occupied. The applicant’s ability to satisfy the criteria of the fellowship requirements should be specifically addressed.

Name

First Last

Title

Chair, Department of Surgery

Institution

Name

First Last

Title

Institution

Name

First Last

Title

Institution

Questions can be directed to AHNSF Executive Director, Colleen Elkins via email: colleen@ahns.info, or by phone at 310-437-0559.
It is to the applicant’s advantage to submit the completed application as early as possible in advance of the closing date, June 1, 2022.

Please upload your CV(Required)

Max. file size: 512 MB.

Please upload your personal essay(Required)

Max. file size: 512 MB.

Please upload a LOR(Required)

Max. file size: 512 MB.

Please upload a LOR(Required)

Max. file size: 512 MB.

Please upload a LOR(Required)

Max. file size: 512 MB.

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2022 Chris O’Brien Traveling Fellowship Award Application

1. Applicant

Present Academic Position

2. Education

3. Present Hospital Appointments

4. Specialty Certification Designation

5. Fellowship

6. References