Walter P. de Groot Scholarship Application

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* 1. Full Name

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* 2. Email

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* 3. Phone

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* 4. Mailing Address

Street

City

State/Province

Zip

Country

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* 5. Organization

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* 6. Please, upload a letter explaining your commitment to venous and lymphatic disease.

PDF, DOCX, DOC file types only.

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* 7. Please, upload a letter from your preceptor or fellowship leadership explaining your program.

PDF, DOCX, DOC file types only.

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* 8. Please, upload your CV.

PDF, DOCX, DOC file types only.

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* 9. I agree to the terms of the de Groot Award and attest to the information provided in this application. If awarded, I will be available to attend the 2020 Annual Congress in Washington, D.C.

Yes