All fields are required.
Name
First Name
Last Name
Degree(s)
Street Address
City
State
Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Is your ASCRS membership active?
Yes
No
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Current Position, location, and start date (and end date if in training)
Residency Location
Residency Dates
Fellowship Type and Location
Fellowship Dates
Sub-specialization(s), if any
What language do you speak? Please include level of fluency.
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Domestic Volunteer Experience
0/50
International Volunteer Experience
0/50
Administrative/Managerial Experience
0/50
Experience in Public Health
Research Experience (Please summarize. Do not list papers)
Technical or entrepreneurial experience.
When would you be available to volunteer? How much time would you have?
Is there a region you have a personal connection to? Is there a region you have a special interest in serving?
0/50
In what ways would you like this grant to prepare you for future participation in the field of global ophthalmology, such as: providing clinical and/or surgical training, public health experience, eye program management, sustainability training, teaching, or leadership?
0/50
What do you most want to learn from an experience you could fund with this grant?
0/50
ANSWER ONE OF THE NEXT 2 CATEGORIES
IF you are actively involved in or proposing a specific project:
What is the need you would address? Please list the main components, timeline, budget, and , if applicable, supporting mentors/program.
How would this grant enhance your project?
What do you plan to do with funding in preparation for your travel abroad, if it's needed?
What do you hope to accomplish and learn by traveling abroad, if that is part of your project?
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OR, if you do not have a specific project,-
Please elaborate on any ideas you have for a project or experience you'd like to have, and/or what you'd like to learn by preparing and potentially (though not necessarily) traveling to your project site?
Is there anything else you'd like us to know?
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Section 5: Applicant CV and References
Instructions:
Upload your resume or CV.
Provide the contact information for three references in the requested field.
One letter of recommendation from one of your references is required. Upload the letter of recommendation (no more than one page in length) addressing both your clinical and surgical skills along with your character.
Reference 1
Include name, affiliation, phone, and email. Letter required below.
Reference 2
Include name, affiliation, phone, and email. Letter is not required.
Reference 3
Include name, affiliation, phone, and email. Letter is not required.
Letter of recommendation
*
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