Service,(Education(and(Support(for(Underserved(Communities( ! ! Dr.$Benigno$S.$Aldana$Jr.$$ Neurosurgery$Educational$Award$ Application$ $ $ OBJECTIVE$ The!Neurosurgery!Outreach!Foundation,!Inc.!(“NOF”!or!“the!Foundation”)!is!an!organization!whose! mission!is!to!promote!the!advancement!of!neurosurgical!care!in!underserved!communities!through! service,! education! and! support.! ! Communities! lacking! in! modern! neurosurgical! care! will! be! the! focus! of! the! services! of! the! NOF,! by! working! primarily! with! local! medical! organizations.! ! NOF! provides!educational!awards!to!benefit!a!neurological!surgery!resident!or!trainee,!who!practices!in! an! underserved! community,! and! assist! them! in! the! successful! completion! of! their! training! and! to! help!defray!their!neurosurgery!educational!costs.! $ $ $ ELIGIBILITY$ ! The!candidate!must!fulfill!the!following!requirements!to!be!eligible!for!the!award:! a. Resides!or!practices!in!an!underserved!community.! b. Is!a!neurological!surgery!resident!or!trainee!in!good!standing.! c. Belongs!to!a!neurosurgery!program!that!services!an!underserved!community.! d. Demonstrates!academic!and!surgical!excellence.! ! ! ! ! ! ! ! ! The!Neurosurgery!Outreach!Foundation,!Inc.! PO!Box!8201,!Jacksonville,!Florida!32239D8201,!USA!!!EDmail:[email protected]!www.neurosurgeryoutreach.org! ! Service,(Education(and(Support(for(Underserved(Communities( ! ! APPLICATION$GUIDELINES$ $ The!application!must!be!completed!by!the!candidate,!approved!by!the!Residency!Program!Director! and!submitted!with!the!necessary!documents!as!stated!hereunder.!The!Foundation!will!accept!one! application! per! award.! All! applications! must! be! received! no! later! than! 8th! December,! 2014,! for! consideration.! A! written! response! will! be! mailed! to! the! Program! Chair! and! to! the! awardees.! The! award(s)!will!be!announced!in!the!NOF!and!AAACPN!website!and/or!newsletter.!! ! The!submission!requirements!include:! 1. Application!Form!! 2. Letter!of!recommendation!from!Residency!Program!Director! 3. Curriculum!Vitae! 4. Personal!narrative!! ! The!personal!narrative!should!include!at!least!the!following:! 1.!!!Information!on!the!applicant,!the!community!he/she!is!from!and!his!training!program.!!! 2.! ! Information! regarding! how! he! or! she! plans! to! use! the! knowledge! gained! from! the! AAACPN! course!to!help!the!medically!underserved!population!in!his/her!community.! ! Any! application! submitted! with! insufficient! information/documentation! or! is! improperly! completed!will!be!returned!for!revision!(if!time!permits)!and!may!not!be!included!for!consideration! for!the!given!year.!!!Applications!from!previous!awardees!will!not!be!considered.! ! Keep!a!copy!of!the!application!for!your!records.! ! AWARDS$ ! A! selection! committee! that! consists! of! representative(s)! of! the! Foundation! will! determine! the! award! recipient.! Multiple! recipients! from! the! same! residency! program! may! receive! an! award.! However,!individual!applications!are!required.! ! The!value!of!the!award!will!be!equal!the!cost!of!the!registration!fee!for!the!2015!Asian!Australasian! Advanced!Course!in!Paediatric!Neurosurgery!(AAACPN).! ! An!award!letter!will!be!mailed!to!the!applicant!and!a!copy!furnished!to!his/her!residency!program.! All! awards! will! be! presented! in! US! dollars! paid! directly! to! the! course! organizers.! Any! applicable! local!tax!obligations!are!solely!the!responsibility!of!the!award!recipient.!! $ $ The!Neurosurgery!Outreach!Foundation,!Inc.! PO!Box!8201,!Jacksonville,!Florida!32239D8201,!USA!!!EDmail:[email protected]!www.neurosurgeryoutreach.org! ! Service,(Education(and(Support(for(Underserved(Communities( ! ! $ APPLICATION$FORM$ ! Residency!Program:!________________________________________________________________________________________! ! ! Number!of!residents!admitted!per!year:!____________!! ! ! Medical!Organization/Center:!_____________________________________________________________________! ! ! ! Address:______________________________________________________________________________________________! ! ! ______________________________________________________________Country:_______________________________! ! ! ! Telephone!Number!(s):!___________________________________Fax!Number:___________________________! ! ! Program!Chair/Director:!___________________________________________________________________________________! ! ! Telephone!Number!(s):!__________________________________!Email:!__________________________________! ! Award!Applicant!Name:!__________________________________________________________________________________! ! ! ! Address:!__________________________________________________________________________________________! ! ! ____________________________________________________________________Country:!______________________! ! Year!in!Residency:!!_______________________________________________________________________________! ! ! ! $SUBMIT$APPLICATIONS$TO:$ Mail:! Neurosurgery!Outreach!Foundation,!Inc.! PO!Box!8201,!Jacksonville,!! FL!32239a8201!!!USA! Attention:!Education! ! Scan!and!email:[email protected]! ! ! ! ! ! ! The!Neurosurgery!Outreach!Foundation,!Inc.! PO!Box!8201,!Jacksonville,!Florida!32239D8201,!USA!!!EDmail:[email protected]!www.neurosurgeryoutreach.org! ! Service,(Education(and(Support(for(Underserved(Communities( ! ! ! ! Previous!Application!on!File:![!]!Yes![!]!No!!!!!!!!!!Year!(s)!Submitted:!___________________________________! ! Number!of!Application!Previously!Submitted:!_____________! ! Letter!of!Recommendation!Included:![!]!Yes!![!]!No! Curriculum!Vitae!Included:![!]!Yes!![!]!No! ! Additional!Documents!Included:![!]!Yes![!]!No! ! Please!list:!!! 1.!_________________________________________________________________________________! ! ! ! 2.!_________________________________________________________________________________! ! ! ! 3.!_________________________________________________________________________________! ! !! ! Residency!Program!Chair!Signature:!____________________________________________________________________! ! Date:!________________________________________________________________________________________________________! ! ! ! ! Foundation!Use:! ! ! Date!received:!_______________________________!!!Reviewed!by:!_____________________________________________! LoR:![!]!!!!PN:![!]!!CV:![!]!!O:![!]! ! Action:!______________________________________________________________________________________________________! ! _______________________________________________________________________________________________________________! ! ! $ The!Neurosurgery!Outreach!Foundation,!Inc.! PO!Box!8201,!Jacksonville,!Florida!32239D8201,!USA!!!EDmail:[email protected]!www.neurosurgeryoutreach.org! !
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