1. Name of applicant.
2. Cell phone number.
3. Education/Post Graduation Education (List Residency): List the College or University you graduated from including date, as well as Post-Graduate Education and the dates.
4. Date of ABOS certification.
5. List Military Service dates (if applicable): Please list Branch of service/Rank/Duties.
6. Professional Employment/Teaching Affiliations: Please list in chronological order the Academic Title, Teaching Responsibilities, and the dates.
7. Faculty Involvement: List Residency, Fellowship, Regional, National, International course faculty involvement.
8. Visiting Professorships/ Invited Lectures: List any visiting professorships or invited lectures given (Include location, date, and title of lecture if applicable).
9. Special Awards and Honors: List special awards and honors received while in medical school, residency, fellowship or following the completion of your educational program; Include any research awards received.
10. Additional Education or Fellowship: List type of Education or Fellowship, the name of Director, and the dates.
11. Peer-reviewed Articles (Published and In Press): List articles published in peer-reviewed journals. Include the title, all authors, journal, and year of publication. Please underline your name and capitalize the name of the journal. You may also list articles in press but not those that are submitted only; please indicate whether they are published or in press.
12. Non-Peer-Reviewed Articles: List articles published in non-peer-reviewed journals (include internet related articles here).
13. Textbooks and Textbook Chapters: List textbooks or chapters in textbooks that you have authored or co-authored. Identify title, publisher, all authors, and the year.
14. Regional and Local Scientific Presentations: List scientific presentations that you gave at regional and local meetings (include title of paper, all authors, organization, location and date).
15. National and International Scientific Presentations: List scientific presentations that you gave at national and/or International meetings, and/or a presentation at the AOA Meeting (include title of paper, all authors, organization, location and date).
16. Peer-Reviewed Research Grants: List peer-reviewed research grants you have received (i.e. NIH, OREF), and the amount and source of each grant. List your role on grant (PI, co-PI, investigator).
17. AOA Affiliations: Please list any previous or current affiliation with the AOA. i.e., Resident Leadership Forum Participant, Emerging Leader, CORD Affiliate Institution, Committee Member, etc.
18. Membership/Leadership Positions: List membership or leadership positions you have held on National, Regional or Local committees or in professional organizations. This includes Editorial Boards, Committee Positions, etc.
19. Non-Academic Achievements and Community Service Activities: Describe any special nonacademic achievements or community service activities which you believe are important; i.e., civic activities, church, Girl/Boy Scouts, Chamber of Commerce, etc.