Embed Size (px)
Citation preview
GRANT APPLICATION
PEDIATRIC NEPHROLOGY SEMINAR XLVI :NEW ADVANCES AND OLD CONTROVERSIES
March 8-10, 2019Royal Palm South Beach
Miami Beach, FL, USA
COMPLETION OF THE SEMINAR REGISTRATION FORM ALSO IS REQUIREDTO FAX THE GRANT APPLICATION, PLEASE SUBMIT TO 305-585-7025
DEADLINE IS DECEMBER 31, 2018
Your Institution: ________________________________________________________
Indicate your department and division: _________________________________________________
Select one: PGY __1 __2 __3 __4 __5 __6 __7 __Young Faculty __Other Faculty
PERSONAL DATAName in full (First Middle Last): _____________________________________________________
Current mailing address: ________________________________________________
Street: _______________________________________________________________
City: State: Zip code: ___________________________________________________
Telephone: ___________________________ Fax: ___________________________
E-mail (REQUIRED): ____________________________________________________
STATISTICAL INFORMATION
Place of birth: _______________________________ Date of birth: _______________
EDUCATION
Medical School Name: __________________________________________________________
1
Location (City & State): __________________________________________________________
Degree: _______________________________ Date of Graduation: _______________
List chronologically your professional activities from the time of graduation from Medical School. Specify type of post-graduate training. (For additional space, use a separate sheet)Suggested format: From (date), To (date) , Activity, Place, Degree (If any)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
EXPERIENCE (For additional space, use a separate sheet)
Clinical and/or Research Experience:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Professional Practice, location and dates:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Publications and Memberships in professional societies:
2
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Plans after completing training or after “Young Faculty” position:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
In addition to the Grant Application, also forward via fax or e-mail:
A recent photograph, a letter from your Division Director, Training Program Director, or Department
Chairman stating that, if selected for the Partial Travel Grant Award of a maximum of $400.00 and free registration, the Division or Department will be responsible for the other expenses,
a three hundred word typed biographical sketch would be helpful.
USE THE FOLLOWING name, fax number, and e-mail to submit all documents:
Gaston Zilleruelo, M.D.Professor of Pediatrics and DirectorDivision of Pediatric Nephrology, Department of PediatricsUniversity of Miami Miller School of Medicine
Fax: 305-585-7025
E-mail: [email protected]
3
