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* 1. Name

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* 2. Credentials / Certifications

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* 3. Email Address

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* 4. Cell Phone Number

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* 5. Mailing Address

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* 6. PA School & Graduation Year

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* 7. Current Employer

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* 8. City & State of Practice

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* 9. Please indicate your SDPA Membership. Only Fellow and Associate members may apply to the program. You must be a current SDPA member to be eligible.

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* 10. How did you hear about the Emerging Scholar Program?

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* 11. Upload your CV/resume (PDF).

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* 12. Upload a high-quality headshot (PNG, JPG, or JPEG).

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* 13. Outline your volunteer, committee, and leadership roles or experiences.

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* 14. What motivates you to pursue a career in dermatology?

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* 15. Do you prescribe medication for psoriasis patients?

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* 16. Are you familiar with various psoriasis treatment options?

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* 17. In what ways will this program help you refine your patient care practices?

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* 18. Scholarship recipients are asked to share highlights of their experience before, during, and after the conference on social media, tagging SDPA in their posts. If selected, are you willing to fulfill this requirement?

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* 19. If yes, please provide your social media handle(s).

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* 20. If selected for this program, SDPA plans to take photographs, audio, and video during the conference, and reserves the right to use any photograph/video taken during any SDPA event without the expressed written permission of those included within the photograph/video. SDPA may use the photograph/video in SDPA educational, news, or promotional material.

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* 21. If selected for this program, I agree to (1) arrive onsite at the conference hotel in time to attend the Luncheon & Mentor Meet-up and Scholars Workshop, (2) attend all conference sessions Wednesday through Sunday, including receptions, (3) participate in all activities hosted in the Scholars Lounge, (4) complete the post-program evaluation survey, and (5) share aspects of my experience related to the scholarship on my personal social media account(s) during my time at conference.

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