LastName,FirstName
ACAPSGlobalHealthCommittee
PSENGlobalScholarshipApplication
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DEADLINEforscholarshipapplicationisJune15,2016.
Refertocriteriabelowforeligibilityrequirements.
Refertoapplicationprocessbelowforalistofthesupportingdocumentsneeded.
Ifanyquestiondoesnotapplytoyouinthisapplication,pleaseputN/Ainthespace.
Typeorprintlegibly.Illegibleapplicationswillbereturnedtoyou.
Pleasesubmita3”x5”colorphotographofyourself,notexceeding1MB.
Youwillbenotifiedbyemailregardingthestatusofyourapplication.
Ifyouhaveanyquestionsabouttheapplicationorscholarship,pleasecontactRebeccaBonsaint.
Purpose:Toprovideaone-yearsubscriptiontothePlasticSurgeryEducationNetwork(PSEN)fora
surgicaltraineeorsurgicaltrainingprogramfromresourcepoorarea.
AwardComponents:OneyearsubscriptiontothePSENforonesurgicaltraineeorsurgicaltraining
programselectedbytheAmericanCouncilofAcademicPlasticSurgeons(ACAPS)GlobalHealth
CommitteeandapprovedbytheAmericanSocietyofPlasticSurgeons(ASPS)andPSENEditorialBoard.
Criteria:
1. Applicantmustbeasurgicaltraineeoratraineeactingastherepresentativeofasurgical
trainingprogramwhoisactivelypursuingclinicalplasticsurgeryeducation.
2. Applicantmustbeactivelyenrolledinasurgicaltrainingprogramthatincludesclinicalplastic
surgeryinalowormiddle-incomecountry.
3. Applicantmustprepareanessayonwhattheyplantodowiththeirplasticsurgeryeducation
aftercompletionoftheirsurgicaltraining.
4. Applicantmustprovidetwo(2)lettersofreferencefromeducators,supervisors,andcurrent
ProgramDirector.
5. ApplicantmustsubmitacurrentCVwiththeapplication.
6. ApplicantmustsubmitaformalevaluationofPSENatthecompletionofthescholarship.
Oncecompleted,pleasesubmitallyourinformationasfollows:
ByMail:
ATTN:RebeccaBonsaint
AssociateExecutiveDirector
AmericanCouncilofAcademicPlasticSurgeons
500CummingsCenter,Suite4550
Beverly,MA01915
ByEmail:
rbonsaint@prri.com
ByFax:
ATTN:RebeccaBonsaint
FaxNumber:+1978-524-0461
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LastName,FirstName
Date______________________
ApplicationType:
___IndividualPlasticSurgeryTrainee
___PlasticSurgeryTrainingProgram
NameandLocationofTrainingProgram
___________________________________________________________________________
NumberofSurgicalTraineesinProgramRequestingPSENAccess_____
ProgramDirector’sName:_____________________________________________________
LASTNAME FIRSTNAME MIDDLEINITIAL
1.Applicant’sFullName:_____________________________________________________
LASTNAME FIRSTNAME MIDDLEINITIAL
2.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-MAILADDRESS
4. Gender:Male____
Female____
5. FinancialPosition
DoesYourTrainingProgramProvideYouwithFinancialSupport?___________________
IfYes,HowMuchAnnually(USDollars)?_________________________________
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LastName,FirstName
DoYouHaveAnotherSourceofIncome?_______________________________________
IfYes,PleaseDescribetheSourceandtheAmount(USDollars)_______________
__________________________________________________________
TotalAnnualIncome(USDollars)________________________________________________
6. SecondaryEducation:
NameofSchool
Location
DatesAttended
7. UniversityEducation:
NameofSchool
Location
DatesAttended
8. MedicalEducation:
NameofSchool
Location
9. PostGraduateTraining:
NameofTrainingProgram
City,State
ProgramDirector
10.CurrentTrainingProgramDescription:
DegreeandDate
ofDegree
YearsAttended
NameofTrainingProgram
DatesAttended
DegreeandDate
ofDegree
NumberofFaculty
Graduated?
Durationoftraining
ProgramDescription(Pleaseprovideabriefdescriptionoftheprogramstructure,clinicalanddidactic
curriculum,andleveloffacultysupervision)
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LastName,FirstName
ProgramResources(Pleaseprovideabriefdescriptionoftheaccesstocomputerequipment,internet
availability,andeducationalresources)
11.HonorsandAwards:
NameofHonororAward
Year
Description
12.References:(pleaseattachatleasttworeferenceletters,onefromcurrentProgramDirector)
LastName,FirstName
Relationship
Phone
Email
13.PersonalEssay
Pleaseattachonseparatesheetapersonalessayonwhyyouareapplyingforthisscholarshipandwhat
youplantodowiththeirplasticsurgeryeducationaftercompletionofyoursurgicaltrainingmustbeat
leasttwoparagraphs.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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