Application for the WDS Mentorship Grant Awards Program

WOMEN’S DERMATOLOGIC SOCIETY
2008 WDS Mentorship Grant Awards Program Application

Application Deadline Has Expired: November 7, 2007
(Look for the 2009 application coming in early 2008)

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Check ALL that apply:

Member of WDS
Resident
Fellow
Jr. Faculty

APPLICANT INFORMATION:

Application Date:

Name:
E-Mail:
Address:
City:
State:
Zip:
Telephone:
Fax:
Current Position Held:
List Details Here

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, 2008)
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)

Application Deadline Has Expired: November 7, 2007
(Look for the 2009 application coming in early 2008)

64k file size | 9 seconds @56k
Viewing Help

This grant program generously sponsored by: Dermik Laboratories