ASPS/Operation Smile International Scholar Program …



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OPERATION SMILE & THE PLASTIC SURGERY FOUNDATION INTERNATIONAL SCHOLAR PROGRAM APPLICATION

for funding in 2019

Application must be typed and submitted to rvaladez@ no later than July 31, 2019

(Please begin typing in the shaded box the box will expand as you type.)

Date:    

Last Name:      

First Name:      

Middle Name:      

Date of Birth (Month/Day/Year):       Male Female

Nationality:      

Citizenship:      

Current Position and/or Title:      

Business Address

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Apt. No.:      

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Facsimile (Fax): Country Code:       Area Code:       Number:      

Email Address:      

Home Address

Street:      

Apt. No.:      

City:      

State/Province:      

Country:      

ZIP/Postal Code:      

Telephone: Country Code:       Area Code:       Number:      

Facsimile (Fax): Country Code:       Area Code:       Number:      

Email Address:      

Address to be used for correspondence: Business Home

Academic Appointments

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Title/Rank:      

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Education and Training

Undergraduate (College or University)

Institution:      

Location:      

Year Graduated:      

Highest Degree Obtained:      

Medical School

Institution:      

Location:      

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Highest Degree Obtained:      

Graduate School

Institution:      

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Residency (Surgery)

Institution:      

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Highest Degree Obtained:      

Residency (Plastic Surgery)

Institution:      

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Highest Degree Obtained:      

Fellowship

Institution:      

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Certification

Certifying Board (or equivalent) in Plastic Surgery:      

Date of Certification (Month/Day/Year):      

Honors and Awards:      

Civic and Community Activities:      

Professional Organizations and Societies:      

Clinical Interests and Special Expertise:      

Research Interests and Special Expertise:      

Presentations at Scientific Meetings:      

Papers Published in Referred Journals:      

Papers Published as Invited Articles or Chapters:      

Books or Monographs Published:      

Visits Abroad During the Past Ten Years

Country/Area:      

Purpose and Sponsorship:      

Dates of Stay:      

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Have you ever worked outside of the United States or Canada?

Yes, please describe briefly No

     

Past Surgical Experience:

How many cleft lip surgeries have you performed in the past year?      

in the past 5 years?      

in your surgical career?      

How many cleft palate surgeries have you performed in the past year?      

in the past 5 years?      

in your surgical career?      

What is your experience with burns (be specific)?      

How many burn cases have you performed in the past year?      

How many burn cases have you performed in the past five years?      

What is your experience with hand surgery (be specific)?      

How many hand surgery cases have you performed in the past year?      

How many hand surgery cases have you performed in the past five years?      

Are you experienced and comfortable performing Pharyngoplasties?      

How did you hear of this program?

Plastic Surgery News®

Maxillofacial News

Direct Mail Correspondence

Other:      

Application must be received NO LATER than July 31, 2019 for consideration of funding in 2019. Applicants will be notified of a funding decision by September 22, 2019.

Electronic submission is required. Submit this completed application and all supporting documents to: Ms. Romina Valadez at rvaladez@

Please enclose your CV with your completed application. Letters of support from your colleagues are welcomed.

Signature: __________________________________________________________________Date: ___________

Questions? Contact Ms. Romina Valadez at rvaladez@

ASPS/PSF and Operation Smile International Scholar Program

American Society of Plastic Surgeons

444 East Algonquin Road

Arlington Heights, IL 60005

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