Application for the Career & Community Advancement Award

WOMEN’S DERMATOLOGIC SOCIETY
Career & Community Advancement Award Application
Applications are reviewed twice a year: June 30, 2010 & December 31, 2010
(Exceptions may be made for time sensitive requests)

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You must be a member of the WDS for at least three years post-residency to apply for this award!

Have you ever applied for a Career & Community Advancement Award with WDS in the past?
Yes | No

If yes, were you accepted?
Yes | No

APPLICANT INFORMATION:

Name:
E-Mail:
Address:
City:
State:
Zip:
Telephone:
Fax:
Current Job Description (ie, private practice, faculty… etc.)
List Details Here

MENTOR OR COURSE FACILITY INFORMATION

Name:
E-Mail:
Address:
City:
State:
Zip:
Telephone:
Fax:

Area of Expertise:
Focus/Program Title:
Beginning Date:
Ending Date:

Location:
City:
State:
Zip:
Telephone:
Fax:

BUDGET REQUEST:

You may eMail a separate budget worksheet if you wish, or use the space below. Keep in mind any additional expenses you may encounter, such as malpractice insurance.
• Tuition / Fees	$
• Transportation	$
• Lodging	$
• Food	$
• Other (describe below)	$
TOTAL REQUEST	$
List Details Here

STATEMENT OF PURPOSE TO INCLUDE THE FOLLOWING POINTS:

In your Statement of Purpose, describe your career development goals.
Describe the goal(s) of the proposed development program and any specifi c project planned.
How do you envision this development program will impact your future career development in dermatology?
How will this experience specifically help prepare you to be a leader in dermatology?

CURRICULUM VITAE:

2 LETTERS OF REFERENCE:

One from potential mentor that defines the content of the development program with the beginning and ending dates (or a copy of the Course Program Brochure) and a letter of recommendation from a WDS Member. (May be sent separately)

Applications are reviewed twice a year: June 30, 2010 & December 31, 2010

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The WDS Career & Community Advancement Award is supported by Galderma Laboratories.