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Last Name, First Name Page 1 of 4 ACAPS Global Health Committee PSEN Global Scholarship Application 1. DEADLINE for scholarship application is June 15, 2016. 2. Refer to criteria below for eligibility requirements. 3. Refer to application process below for a list of the supporting documents needed. 4. If any question does not apply to you in this application, please put N/A in the space. 5. Type or print legibly. Illegible applications will be returned to you. 6. Please submit a 3”x5” color photograph of yourself, not exceeding 1 MB. 7. You will be notified by email regarding the status of your application. 8. If you have any questions about the application or scholarship, please contact Rebecca Bonsaint. Purpose: To provide a one-year subscription to the Plastic Surgery Education Network (PSEN) for a surgical trainee or surgical training program from resource poor area. Award Components: One year subscription to the PSEN for one surgical trainee or surgical training program selected by the American Council of Academic Plastic Surgeons (ACAPS) Global Health Committee and approved by the American Society of Plastic Surgeons (ASPS) and PSEN Editorial Board. Criteria: 1. Applicant must be a surgical trainee or a trainee acting as the representative of a surgical training program who is actively pursuing clinical plastic surgery education. 2. Applicant must be actively enrolled in a surgical training program that includes clinical plastic surgery in a low or middle-income country. 3. Applicant must prepare an essay on what they plan to do with their plastic surgery education after completion of their surgical training. 4. Applicant must provide two (2) letters of reference from educators, supervisors, and current Program Director. 5. Applicant must submit a current CV with the application. 6. Applicant must submit a formal evaluation of PSEN at the completion of the scholarship. Once completed, please submit all your information as follows: By Mail: ATTN: Rebecca Bonsaint Associate Executive Director American Council of Academic Plastic Surgeons 500 Cummings Center, Suite 4550 Beverly, MA 01915 By Email: [email protected] By Fax: ATTN: Rebecca Bonsaint Fax Number: +1 978-524-0461

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Page 1: 2016PSEN Global Scholarship Application-JE · 3. Refer to application process below for a list of the supporting documents needed. 4. If any question does not apply to you in this

LastName,FirstName

Page1of4

ACAPSGlobalHealthCommitteePSENGlobalScholarshipApplication

1. DEADLINEforscholarshipapplicationisJune15,2016.2. Refertocriteriabelowforeligibilityrequirements.3. Refertoapplicationprocessbelowforalistofthesupportingdocumentsneeded.4. Ifanyquestiondoesnotapplytoyouinthisapplication,pleaseputN/Ainthespace.5. Typeorprintlegibly.Illegibleapplicationswillbereturnedtoyou.6. Pleasesubmita3”x5”colorphotographofyourself,notexceeding1MB.7. Youwillbenotifiedbyemailregardingthestatusofyourapplication.8. Ifyouhaveanyquestionsabouttheapplicationorscholarship,pleasecontactRebeccaBonsaint.

Purpose:Toprovideaone-yearsubscriptiontothePlasticSurgeryEducationNetwork(PSEN)forasurgicaltraineeorsurgicaltrainingprogramfromresourcepoorarea.AwardComponents:OneyearsubscriptiontothePSENforonesurgicaltraineeorsurgicaltrainingprogramselectedbytheAmericanCouncilofAcademicPlasticSurgeons(ACAPS)GlobalHealthCommitteeandapprovedbytheAmericanSocietyofPlasticSurgeons(ASPS)andPSENEditorialBoard.Criteria:

1. Applicantmustbeasurgicaltraineeoratraineeactingastherepresentativeofasurgicaltrainingprogramwhoisactivelypursuingclinicalplasticsurgeryeducation.

2. Applicantmustbeactivelyenrolledinasurgicaltrainingprogramthatincludesclinicalplasticsurgeryinalowormiddle-incomecountry.

3. Applicantmustprepareanessayonwhattheyplantodowiththeirplasticsurgeryeducationaftercompletionoftheirsurgicaltraining.

4. Applicantmustprovidetwo(2)lettersofreferencefromeducators,supervisors,andcurrentProgramDirector.

5. ApplicantmustsubmitacurrentCVwiththeapplication.6. ApplicantmustsubmitaformalevaluationofPSENatthecompletionofthescholarship.

Oncecompleted,pleasesubmitallyourinformationasfollows:

ByMail: ATTN:RebeccaBonsaint AssociateExecutiveDirector AmericanCouncilofAcademicPlasticSurgeons 500CummingsCenter,Suite4550 Beverly,MA01915

ByEmail: [email protected]

ByFax: ATTN:RebeccaBonsaint FaxNumber:+1978-524-0461

Page 2: 2016PSEN Global Scholarship Application-JE · 3. Refer to application process below for a list of the supporting documents needed. 4. If any question does not apply to you in this

LastName,FirstName

Page2of4

Date______________________ApplicationType:___IndividualPlasticSurgeryTrainee___PlasticSurgeryTrainingProgram NameandLocationofTrainingProgram ___________________________________________________________________________ NumberofSurgicalTraineesinProgramRequestingPSENAccess_____ProgramDirector’sName:_____________________________________________________ LASTNAME FIRSTNAME MIDDLEINITIAL1.Applicant’sFullName:_____________________________________________________ LASTNAME FIRSTNAME MIDDLEINITIAL2.Birthdate:Month_______Day_______Year________3.CompleteAddress: _____________________________________________________Apt/Suite_______ STREETADDRESS ___________________________________________________________________ STREETADDRESS(SECONDLINE) ___________________________________________________________________ CITY STATE/PROVINCE POSTALCODE/ZIPCODE ___________________________________________________________________ COUNTRY ___________________________________________________________________ PHONE(222-333-4444) E-MAILADDRESS ___________________________________________________________________ MESSAGEPHONE(222-333-4444) ALTERNATEE-MAILADDRESS4. Gender:Male____ Female____

5. FinancialPosition

DoesYourTrainingProgramProvideYouwithFinancialSupport?___________________IfYes,HowMuchAnnually(USDollars)?_________________________________

Page 3: 2016PSEN Global Scholarship Application-JE · 3. Refer to application process below for a list of the supporting documents needed. 4. If any question does not apply to you in this

LastName,FirstName

Page3of4

DoYouHaveAnotherSourceofIncome?_______________________________________IfYes,PleaseDescribetheSourceandtheAmount(USDollars)_______________

__________________________________________________________TotalAnnualIncome(USDollars)________________________________________________

6. SecondaryEducation:

NameofSchool Location DatesAttended

7. UniversityEducation:

NameofSchool Location DatesAttended DegreeandDate

ofDegree

8. MedicalEducation:

NameofSchool Location DatesAttended DegreeandDate

ofDegree

9. PostGraduateTraining:

NameofTrainingProgram City,State YearsAttended Graduated?

10.CurrentTrainingProgramDescription: NameofTrainingProgram ProgramDirector NumberofFaculty Durationoftraining

ProgramDescription(Pleaseprovideabriefdescriptionoftheprogramstructure,clinicalanddidacticcurriculum,andleveloffacultysupervision)

Page 4: 2016PSEN Global Scholarship Application-JE · 3. Refer to application process below for a list of the supporting documents needed. 4. If any question does not apply to you in this

LastName,FirstName

Page4of4

ProgramResources(Pleaseprovideabriefdescriptionoftheaccesstocomputerequipment,internetavailability,andeducationalresources)

11.HonorsandAwards:

NameofHonororAward Year Description

12.References:(pleaseattachatleasttworeferenceletters,onefromcurrentProgramDirector)

LastName,FirstName Relationship Phone Email 13.PersonalEssayPleaseattachonseparatesheetapersonalessayonwhyyouareapplyingforthisscholarshipandwhatyouplantodowiththeirplasticsurgeryeducationaftercompletionofyoursurgicaltrainingmustbeatleasttwoparagraphs.Pleaselimitto500words.

~Allscholarshipinformationiskeptconfidential~If you receive a scholarship, would you be willing to volunteer to serve on the PSEN Editorial Committee following your training, to help contribute content and further develop the site?

Yes No

Bysigningbelow,Icertifythattheaboveinformationistrueandcorrect.______________________________________ ___________________Signature Date_______________________________________PrintName


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