"Be worthy to Serve the Suffering" Alpha Omega Alpha Honor Medical Society Key Background

Postgraduate Fellowship

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* Salutation
* First Name
* Last Name
Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
* Street 1
Street 2
* City
* State
* Zip
* Phone
* E-mail

* Year of Residency
* Title of proposal
Program Specialty
* School
* Councilor

Mentor First Name
Mentor Last Name
Mentor Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
Mentor Email
Mentor Street 1
Mentor Street 2
Mentor City
Mentor State
Mentor Zip

Program Director First Name
Program Director Last Name
Program Director Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
Program Director Email
Program Director Street 1
Program Director Street 2
Program Director City
Program Director State
Program Director Zip

Department Chair First Name
Department Chair Last Name
Department Chair Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
Department Chair Email
Department Chair Street 1
Department Chair Street 2
Department Chair City
Department Chair State
Department Chair Zip

IRB/IACUC Required? Yes No
Postgraduate Fellowship Submission
Note: Files must be submitted in one PDF in the following order:
1. Completed Checklist
2. 4 page summary with title, background information, project description and goals, potential significance, proposed budget, estimated time commitment, acronym definition list
3. Bibliography of the project
4. IRB or IACUC approval, or proof of application
5. Applicant’s CV
6. Letter of support from Mentor
7. Mentor biosketch
8. Letter of nomination from residency of fellowship program director, including a commitment to allow time of complete project
9. Letter of endorsement from department chair