Covid-19 Resident Education Grant Application

Covid-19 Resident Education Grant Application

Fiscal Year 2020 - 2021
This grant application is for currently enrolled PGY2/PGY3 osteopathic ophthalmologist or PGY3/PGY4 osteopathic otolaryngologist. Residency program ACGME accreditation is not a factor for qualification. Proof of attendance, receipt(s) of payment and a current, signed W-9 form are required.
Email*
example@example.com
Name*

First NameMiddle NameLast NameSuffix
Address where you want check mailed*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PGY Status*
Name of Residency Program*
Program Director's Full Name*
Program Director's Email Address*
example@example.com
Program Director's Phone Number*

Area CodePhone Number
USD Amount seeking to be reimbursed (maximum of $750)*
If you did not ask for the full amount, you can re-apply for an additional grant
Please upload a copy of your receipt, proof of attendance (certificate), and a filled out and signed W-9 form https://www.irs.gov/pub/irs-pdf/fw9.pdf*

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I attest that I am either a PGY2 or a PGY3 osteopathic ophthalmology resident or a PGY3 or PGY4 osteopathic otolaryngology resident. If I miss represent my resident status I shall be asked to return the funds granted to me from the AOCOO-HNS Foundation. Furthermore, I shall be reported to the AOCOO-HNS ethic committee and action may be taken against me.
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