FREDERICK A. COLLER SURGICAL SOCIETY

APPLICATION FOR TRAVELING FELLOWSHIP FOR SURGICAL RESIDENTS

The intent and spirit of the Coller Traveling Fellowship is to provide resources to defray the costs (partially or entirely) of a clinical experience whereby (through the assistance and connections of your Coller Society member sponsor) you travel to another center and gain clinical experience through, for example, observing multidisciplinary clinics or procedures or interacting with leaders in your field. The stipend is reimbursement of travel expenses up to $2000.

TO THE COUNCIL OF THE FREDERICK A. COLLER SURGICAL SOCIETY

I hereby make application for a Frederick A. Coller Traveling Fellowship.

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date and Place of Birth

Are you a citizen of the United States of America or Canada?

Yes

If a Naturalized Citizen, state where and when you were Naturalized

Coller Society Sponsor Member Name

I SUBMIT THE FOLLOWING DATA CONCERNING MY MEDICAL EDUCATION AND SURGICAL TRAINING

Premedical education

University or College

Month/Year

Degree

Medical education

University or College

Month/Year

Degree

Training Following Internship

1. Residency or Fellowship

Residency

Month/Year

Fellowship

Month/Year

2. When will you complete your Surgical Training?

3. If approved, at what time will you take the Traveling Fellowship?

Other Professional Experience such as Basic Science, Private Practice, Investigative Work and Any Special Awards:

Please attach Bibliography (PDF format only)

Choose File

Please include sponsorship letter from a Coller Society Member (PDF format only)

Choose File

Applicant Signature

Date of Application