American Thoracic Society 2011 Resident Travel Award (RTA) Program DEADLINE – Friday, February 18, 2011 INSTRUCTIONS PURPOSE: The American Thoracic Society’s Resident Travel Award (RTA) program is for internal medicine and pediatric residents. The goal of the program is to increase the physician workforce numbers in clinical and research careers in pulmonary and/or critical care medicine by providing an opportunity for residents to attend the ATS International Conference. It is believed that exposure to the excitement of the scientific, translational and clinical information presented at the conference will provide a compelling series of reasons for residents to enter one of these. ELIGIBILITY: An applicant for an ATS Resident Travel Award MUST: Be an internal medicine or pediatric resident who has not been accepted by an adult or pediatric pulmonary and/or critical care, or sleep fellowship program Declare an interest in a career in adult or pediatric pulmonary, critical care or sleep medicine Able to attend the ATS International Conference to receive the award where he/she will be identified with a ribbon recognizing the honor Applicant must not be a recipient of the RTA in 2010 Optional: Additional consideration will be given to applicants who are authors on abstracts accepted for presentation or are presenters at sessions programmed for the ATS International Conference. PROCEDURE: 1. Applicant may submit completed Application Packet to: Elizabeth Guzman Coordinator, Education Programs Email: ATS-RTA@thoracic.org. Fax: 212-315-8651 Phone: 212-315-8627 Note: each application successfully submitted will receive an email confirmation of receipt. 2. An Application Packet will consist of: An Application Form (see next page) which includes an indication of approval of the adult or pediatric residency director for the resident to attend the ATS International Conference in Denver, Colorado. A one-page personal statement from the adult or pediatric resident applicant indicating why he/she is interested in: entering a career in adult or pediatric pulmonary and/or critical care medicine in attending the ATS International Conference A one-page letter of support from a sponsoring ATS member indicating whether he/she is willing to serve as a mentor/guide to the applicant at the International Conference. The sponsoring ATS member is asked to identify another ATS member who can serve this function, if he/she cannot fulfill this responsibility. 3. Applicant must submit a completed Application Packet to ATS by Friday, February 18, 2011. American Thoracic Society 2011 Resident Travel Award (RTA) Program DEADLINE – Friday, February 18, 2011 APPLICATION FORM APPLICANT INFORMATION: Name (First, Middle, Last, and Credentials): Gender (Please check one): Male ________________________________________________________ Female Institution Name (if a work address): Social Security #: _________________________ ____________________________________________________ Street Address line 1: __________________________________________________________________________ Street Address line 2: __________________________________________________________________________ City: _______________________ Tel: _______________________ Are you an ATS member?: State: ____ E-mail: Zip Code: _______________________ _____________________________________________ Yes. My ATS Membership ID is ________ No, I am not an ATS member. Are you an author on an abstract accepted for presentation at the ATS International Conference? Are you a presenter in a programmed session at the ATS International Conference? Yes Yes No No RESIDENCY PROGRAM INFORMATION: Program Type: Internal Medicine I am currently in my Pediatric I am currently a Resident in this program: Yes No __ Resident Year Institution Name (if a work address): ____________________________________________________ Street Address line 1: __________________________________________________________________________ Street Address line 2: __________________________________________________________________________ City: _______________________ State: _______ Zip Code: _______________________ RESIDENCY DIRECTOR INFORMATION: Name (First, Middle, Last, and Credentials): Tel: _______________________ Residency Director’s Signature: ________________________________________________________ E-mail: _____________________________________________ __________________________________________________________________ By my electronic or physical signature, I attest that the information provided here is accurate, and that if selected for an ATS Resident Travel Award, the applicant named above is approved to travel to the ATS International Conference. SPONSORING ATS MEMBER INFORMATION: Name (First, Middle, Last, and Credentials): Tel: _______________________ ________________________________________________________ E-mail: _____________________________________________ APPLICANT’S SIGNATURE AND ATTESTATION: Applicant’s Signature: ________________________________________ Date: ___________________ APPLICANT'S SIGNATURE: By my signature, I attest that the information I have provided here is accurate.