2020 MERF Resident / Faculty Scholarship Application

Please complete the information below and upload a letter from your Program Director. A letter from your Program Director must be uploaded for application to be considered. Note -- priority will be given to residents and fellows who have a faculty applying to attend with them.

Deadline to submit completed applications April 24, 2020

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* 1. CONTACT INFORMATION

First name:

Last name:

Degree(s):

Email:

Phone:

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip:

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* 2. Medical Specialty:

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* 3. Application Type:

Resident

Fellow

Faculty

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* 4. Do you have a DEA waiver to prescribe buprenorphine?

Yes

No

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* 5. If not, will you have one before August 1, 2020?

Yes

No

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* 6. Will there be a faculty member applying with you?

Yes

No

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* 7. Full name of faculty member applying with you:

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* 8. Will there be a resident member applying with you?

Yes

No

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* 9. Full name of resident member applying with you: