WDS Mentorship Awards Program Application | Women's Dermatologic Society

WDS Mentorship Awards Program Application

WOMEN’S DERMATOLOGIC SOCIETY
2012 WDS Mentorship Awards Program Application
Application Deadline: November 1, 2011

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Check ALL that apply:

Member of WDS
Resident
Fellow
Jr. Faculty

APPLICANT INFORMATION:

Application Date:

MENTOR & DEPARTMENT CHAIR INFORMATION:

Mentor Name:
Mentor eMail:
(PLEASE NOTE: You are responsible for accuracy of the Mentor eMail address provided above)
Mentor Address:
Mentor City:
Mentor State:
Mentor Zip:
Mentor Telephone:
Mentor Fax:

Department Chair Name:
Department Chair eMail:
(PLEASE NOTE: You are responsible for accuracy of the Department Chair eMail address provided above)

MENTORSHIP INFORMATION:

Mentorship Focus Is:
Mentorship Beginning Date: (Must begin after April 1, 2011)
Mentorship Ending Date:
Location:
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.
• Transportation	$
• Lodging	$
• Food	$
• Other (describe below)	$
TOTAL REQUEST	$
List Details Here

STATEMENT OF PURPOSE TO INCLUDE THE FOLLOWING POINTS:

Describe your career goals.
Describe the goal(s) of the proposed mentorship and any specific project planned.
How do you envision this mentorship will impact your future career in dermatology?
How will this experience specifically help prepare you to be a leader in dermatology?

List Details Here

CURRICULUM VITAE:

LETTER OF RECOMMENDATION:

From potential Mentor (May be eMailed separately)

From Department Chair (May be eMailed separately)

Deadline for 2012 Awards: November 1, 2011

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This award program generously sponsored by: Dermik Laboratories