ACDS Mid-Career Award Application

Thank you for your interest in applying for the ACDS Mid-Career Grant. Please complete the below information and submit by the designated deadline to be considered for the grant. Please contact info@contactderm.org or call 414-918-9805 with any questions you might have.

* = required field

Applicant's Contact Information

First Name*:

Middle Name:

Last Name*:

Degree(s):

Company/Institution:

Street/Mailing Address:

Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Phone* (include extension):

Email*:

Curriculum Vitae*:

Mentor or Course Information

Statement of Purpose

In your Statement of Purpose, describe your career goals as they relate to the field of contact dermatitis.
Describe the goal(s) of the proposed program and any specific project planned.
How will this program impact your future career development in dermatology?
How will this experience specifically help prepare you to be a leader in contact dermatitis?

Area of Focus (as it relates to Contact Dermatitis)*:

Statement of Purpose*:

Mentor's Details (if applicable)

Name of Mentor:

Email for Mentor:

Mentor Institution:

References

Two (2) Letters of Reference are required. One from the proposed mentor that defines the content of the program (including length of time) and a letter of recommendation from an ACDS Member. If you are applying for a course, please include the course information, for example, a link to the registration and program. The references may also be mailed or faxed separately.

Reference 1:

Reference 2:

Program Location:

Program Dates (from / to):

Budget Request

TOTAL Request:

Budget as PDF or MS Word file:

I certify that the statements in this application are true to the best of my knowledge. I agree that the award funds will be used only for the purpose reflected in my application. Any unused funds will be returned to the ACDS. I hereby agree to provide a written progress report and financial report to the ACDS within 90 days of the termination of my mentorship program.

ACDS Mid-Career Award Application

Applicant's Contact Information

Mentor or Course Information

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