2010 Antonio de la Cruz, MD Memorial Visiting Scholar Application

To attend the AAO-HNSF 2010 Annual Meeting & OTO EXPO

September 26-29, 2010 Boston, Massachusetts, USA
Deadline for receipt of applications (email only)—close of business, May 1, 2010.
Personal Information

Applicant’s Name _________________________________________________________ Today’s Date: ________

Given name Middle Name or Initial Family name Degree (MD, FRCS, PhD, MBBS, etc.)

Applicant’s Title and Position (e.g., Assistant Professor) _______________________________________________

Institution/Medical School _______________________________________________________________________

Work Address:

Street/Office or Suite No. _______________________________________________________________________

City __________________________ State or Province/Postcode ________________ Country

___________________

Phones (include country code) Office (____) ___________ Cell (____) _____________ Fax (____) ____________
Daytime number/extension

E-mail No. 1: ________________________________ Email No. 2 ______________________________________

Home Address:

Street/Apartment No.___________________________________________________________________________

City ___________________________State or Province/Postcode _____________ Country _____________________

Other Information:

Date of Birth ______________ Country of citizenship _________________________________________________

(*Must be a WHO HINARI developing country; see list on page 3)

Passport No. ______________ Passport Issue Date: ______________ Passport Expiration Date: ______________

Professional Information

AAO-HNS Member ID # ________ Medical Degree (MD or equivalent): Year completed: ________
(If available)

Otolaryngology Residency Training program ______________________________ Years: From ______ To ______

Current Department Chair—Full Name ____________________________________________________________

Name of US host or mentor ______________________________________________________________________

Site of Observership in US _______________________________________________________________________
Have you attended an AAO-HNSF Annual Meeting before? ❑ Yes ❑ No
Have you received a US scholarship or travel grant before? ❑ Yes ❑ No
Will you require a visa invitation letter to show the US visa office? ❑ Yes ❑ No
(See other side for application instructions→)

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 2010 Antonio de la Cruz, MD Memorial Visiting Scholar Application
Application Instructions
Please complete and return the application form to Catherine R. Lincoln, CAE, MA (Oxon), Senior Manager,
International/Humanitarian, International Department by email to international@entnet.org with one PDF attachment
including five (5) documents in this order:

1. Antonio de la Cruz, MD Memorial Visiting Scholar Application form

2. Your curriculum vitae (short version of three pages or less)

3. A personal statement of 300 words or fewer, describing

a. your career interests and goals

b. the 2010 Annual Meeting events that you are interested in attending, and

c. the opportunity for an observership. Present your most compelling argument on why a Visiting Scholarship
to attend this meeting and observership are essential to your otolaryngology—head and neck surgery
training and experience.

4. A letter from your Department/Division Chair that certifies you are in good standing in your Department, that the
Chair will allow study leave to attend the Annual Meeting & OTO EXPO plus an observership of one or two weeks,
and describes your strong qualifications for the scholarship.

5. An invitation letter from the US otolaryngology program where you will spend your observership.

Note: please do NOT enclose this instruction sheet with your application. Questions? Contact Catherine R. Lincoln,
CAE, MA (Oxon), Senior Manager, International Department, AAO-HNSF, 1650 Diagonal Road, Alexandria, VA
22314-2857, USA. Tel: 1-703-535-3738, fax 703-684-4428.

Antonio de la Cruz MD Memorial Scholarship: Purpose and Eligibility

Antonio de la Cruz MD Memorial Scholarships are for otolaryngologists from Spanish- and Portuguese-speaking
countries in North, Central, and South America and the Caribbean, who have completed or are currently in
otolaryngology training 1) to attend the American Academy of Otolaryngology—Head and Neck Surgery Foundation
(AAO-HNSF) 2010 Annual Meeting & OTO EXPO, September 26-29, 2009, Boston, Massachusetts, USA, and 2) to
spend one or two weeks studying in an otolaryngology department in the U.S.A.

Each grant of US $2,000 will not fully cover the expenses of attending the Annual Meeting & OTO EXPO and the
observership. The grantee is expected to provide additional funds to cover these costs.

The Antonio de la Cruz MD Memorial Scholar grants are for international otolaryngologists in junior faculty academic
positions, in residency training or not more than five years from completing residency training and age under 40 years.

The following are NOT eligible for these grants:

• Citizens of the U.S.A.
• Citizens from countries that are not Spanish or Portuguese-speaking countries in North, Central, and South
America and the Caribbean
• Foreign nationals who have previously attended an AAO-HNSF Annual Meeting & OTO EXPO.
• Individuals more than five years out of residency or over 40 years of age as of October 1 of the scholarship year.

Candidates may be nominated by the candidate’s national society or by a non-profit organization known to the
Humanitarian Efforts, International Otolaryngology, or Panamerican Committees.

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 2010 Antonio de la Cruz, MD Memorial Visiting Scholar Application
Thank you for your interest in the Academy’s International Visiting Scholar Program
Working for the Best Ear, Nose, and Throat Care Worldwide

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