2019 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 EXTENDED to May 13, 2019 Question Title * 1. CONTACT INFORMATION First name: Last name: Degree(s): Email: Phone: Mailing Address: Mailing City: Mailing State: Mailing Zip: Question Title * 2. Medical Specialty: Question Title * 3. Application Type: Resident Fellow Faculty Question Title * 4. Do you have a DEA waiver to prescribe buprenorphine? Yes No Question Title * 5. If not, will you have one before September 1, 2019? Yes No Question Title * 6. Will there be a faculty member applying with you? Yes No Question Title * 7. Full name of faculty member applying with you: Question Title * 8. Will there be a resident member applying with you? Yes No Question Title * 9. Full name of resident member applying with you: Next