2020 FUTURE FACULTY PROGRAM APPLICATION
Please complete the application in its entirety. At the end of the form, you will be asked to attach your biographical sketch (a paragraph or two), CV, and a personal essay stating why you are interested in pursuing a career in academic optometry and a brief description of your scholarly interests. The application deadline is November 20, 2019 and must be approved by your dean/president prior to submission. Please note that if you are accepted as an attendee, your biographical information will be shared with other attendees and are included in pre-program materials. Please contact LaShawn Sidbury (lsidbury@opted.org) with any questions or concerns.
Applicant Name:
*
First Name
Middle Name
Last Name
Ethnicity:
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Gender:
*
Female
Male
Other
Decline to State
OD Institution:
*
Please Select
AZCOPT
CCO
IAUPR
ICO
IUSO
KYCO
MCO
MCPHS
NECO
NOVA
NSUOCO
OSU
PCO
PUCO
RSO
SCCOMBKU
SCO
SUNY
UABSO
UCBSO
UHCO
UMSL
WUCO
N/A
Current Institution
*
AZCOPT
CCO
IAUPR
ICO
IUSO
KYCO
MCO
MCPHS
Montreal
NECO
NOVA
NSUOCO
OSU
PCO
PUCO
RSO
SCCOMBKU
SCO
SUNY
UABSO
UCBSO
UHCO
UMSL
Waterloo
WUCO
N/A
E-mail Address:
*
Phone Number:
*
-
Area Code
Phone Number
Current Program
*
Please Select
Graduate Student
Resident
*Graduate students must be in a PhD program or nearing the completion of a combined OD/PhD program
Expected Completion Date:
*
-
Month
-
Day
Year
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Please indicate your advisor's name (if applicable):
*
PRIMARY RESPONSIBILITIES:
Didactic:
*
0/50
Patient Care:
*
0/50
Research:
*
0/50
Other:
*
0/50
What do you hope to gain through your attendance at the ASCO Future Faculty Program?
*
Biography (2 paragraphs max)
*
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of
CV
*
Upload a File
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Essay stating why you are interested in pursuing a career in academic optometry and a brief description of your scholarly interests
*
Upload a File
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of
If accepted into the ASCO Future Faculty Program, I accept the responsibility for advance preparation and the completion of pre- and post-program exercises as required.
*
Yes
I attest that I received approval to apply to participate from my dean/president. I understand that my application will be declined if my dean/president has not approved my participation in advance.
*
Yes
O U R G E N E R O U S S P O N S O R
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