Clinical Scholars Application

Question Title

* 1. Program Applying To:

ACS Clinical Scholar - Trauma

ACS Clinical Scholar - Cancer

ACS Clinical Scholar - General

Question Title

* 2. What is your full name?

Question Title

* 3. What is your email address?

Question Title

* 4. What is your address?

Question Title

* 5. What is your date of birth?

Question Title

* 6. What is your phone number?

Question Title

* 7. What is your current PGY level?

Question Title

* 8. Residency Information:

Name of Institution:

Dates Attended:

Address:

Phone:

Fax:

Question Title

* 9. Residency Information:

Name of Institution:

Dates Attended:

Address:

Phone:

Fax:

Question Title

* 10. Education Information:

Medical School:

Dates Attended:

Degree Earned:

Address:

Phone:

Question Title

* 11. Other Graduate School Information:

School:

Dates Attended:

Degree Earned:

Address:

Phone:

Question Title

* 12. College Information:

School:

Dates Attended:

Degree Earned:

Address:

Phone:

Question Title

* 13. Are you a US Citizen?

Yes

If not, are you able to work in the United States? Please explain.

Question Title

* 14. Have you ever been convicted of a felony?

Yes

If yes, please attach a letter explaining the circumstances

Question Title

* 15. Have you ever had a medical license revoked or suspended?

Yes

If yes, please attach a letter explaining the circumstances

Question Title

* 16. Career Plan/ Personal Statement- 1000 Word Limit

In a separate Microsoft Word document, please describe your career plans, where you see yourself in 10 years, and how the ACS Clinical Scholars in Residence Program will further these plans. Include your prior research experience and any relevant statistical, epidemiologic, or programming training.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 17. Research Proposal - 1500 Word Limit

In a separate Microsoft Word document, please describe how your research plans will integrate with the goals of the Department of Research and Optimal Patient Care at the American College of Surgeons.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 18. Curriculum Vitae

In a separate document, please include your curriculum vitae or résumé. Please include 1. Publications (full citations) 3. Awards / Honors 2. Presentations (specify oral or poster; full citations) 4. Previous grants / research funding

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 19. Letters of Recommendation:

Please have your letters of recommendation submitted directly to the cscholars@facs.org email address. Please check this box to acknowledge that your letters of recommendation will be submitted by September 30, 2022

Letter 1: Surgery Department Chairman:
This letter should comment on the applicant’s character, potential, abilities, and career plan. In addition, the Chairman must guarantee to the Selection Committee that the resident will be able to suspend his or her residency for two years to participate in the ACS Clinical Scholars in Residence Program.

Letter 2: Attending Surgeon or Previous Research Mentor.
This letter should comment on the applicant’s character, abilities, potential, and career plan.

Letter 3: Attending Surgeon or Previous Research Mentor.
This letter should comment on the applicant’s character, abilities, potential, and career plan.

Question Title

* 20. Letter 1: Contact Information for Chairman

Name:

Address:

Degree and Title:

Institution:

Email:

Phone:

Question Title

* 21. Letter 1: Contact Information for Letter 2

Name:

Address:

Degree and Title:

Institution:

Email:

Phone:

Question Title

* 22. Letter 1: Contact Information for Letter 3

Name:

Address:

Degree and Title:

Institution:

Email:

Phone: