North American Thrombosis Forum

NATF.Fellowship Application

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NORTH AMERICAN THROMBOSIS FORUM
TRAVELING FELLOWSHIP APPLICATION FOR 2008

*Note: All applications and letters of recommendation must be completed and received in the NATF office by July 15, 2008. Incomplete applications or those received after the deadline will not be considered.

INSTRUCTIONS:

Application can not be saved, you must submit the application after filling out the information.

Candidates must be a resident of North America.

Attach an electronic photograph (.jpg or .gif format) with your application.
Letters of Recommendation should be directed to Arthur A. Sasahara, MD, Chair, NATF Traveling Fellowship Committee, and mailed to the following address: North American Thrombosis Forum; 1620 Tremont Street, Suite 3022; Roxbury Crossing, MA 02120.
Ask three sponsors (note: same as those listed in Section II, 1,2, and 3) to send letters of recommendation to Dr. Arthur A. Sasahara at the above NATF address. One sponsor should be the Attending Physician, Senior Pharmacist, Nursing Director, or Lab Director under whose service you have done the majority of your residency, training, or research and the others should be health care professionals or scientists familiar with your work. Letters of recommendation from the Directors of Training Programs or Fellowships are especially useful. It is the applicant’s responsibility to make sure all forms and letters are received in the NATF office by the specified deadline. Be assured that the NATF office will contact you as soon as one of your letters arrives in the office, but it is solely the applicant’s responsibility to stay in touch with your sponsors and make sure their letters arrive before the deadline.
Submit a personal statement of approximately 500 words, detailing why you want to be a NATF Traveling Fellow, your areas of interest, what you will gain from the program, and what you can offer the program.

If you have any questions about completing the application, please contact Ilene Sussman at (617) 525-8326, or email isussman@NATFonline.org.

* Indicates required fields. Applicants are encouraged to fill out all fields for completeness.

Section I: CONTACT INFORMATION

APPLICANT INFORMATION
* First Name:
Middle Name:
* Last Name:
* Home Phone:		Mobile Phone:
* Age:		* Date of Birth (mm/dd/yyyy):
* Place of Birth:		* Citizenship:
* Home Address:
* City:
* State or Province:
* ZIP or Postal Code:
* Email:
* Photo (Must be JPEG):	Max .jpg file size: 25 KB

WORK INFORMATION
Address:
City:
State or Province:
ZIP or Postal Code:
Office Phone:		Fax:
Email:

Section II: LETTERS of RECOMMENDATION

LETTERS of RECOMMENDATION
First Letter of Recommendation
Name:
Address:
Office Phone:
Email:

Second Letter of Recommendation
Name:
Address:
Office Phone:
Email:

Third Letter of Recommendation
Name:
Address:
Office Phone:
Email:

Section III: EDUCATION

EDUCATION
College/University:
Graduation Date (mm/yyyy):		Degree Earned:

Graduate/Medical School:
Graduation Date (mm/yyyy):		Degree Earned:

POST GRADUATE EDUCATION
1st Year:	Name:
	Location:	Date (mm/yyyy):

2nd Year:	Name:
	Location:	Date (mm/yyyy):

3rd Year:	Name:
	Location:	Date (mm/yyyy):

4th Year:	Name:
	Location:	Date (mm/yyyy):


ADDITIONAL EDUCATION / FELLOWSHIP
Type of Education/Fellowship:
Director:
		From (mm/yyyy): To (mm/yyyy):

Type of Education/Fellowship:
Director:
		From (mm/yyyy): To (mm/yyyy):


PROFESSIONAL ACTIVITIES, PRESENTATIONS, or ORGANIZATIONAL MEMBERSHIPS (provide name, location, month, year, as appropriate)
1. Activity/Organizational Membership:
		Location:
		Date (mm/yyyy):

2. Activity/Organizational Membership:
		Location:
		Date (mm/yyyy):

3. Activity/Organizational Membership:
		Location:
		Date (mm/yyyy):

4. Activity/Organizational Membership:
		Location:
		Date (mm/yyyy):

Special Awards and Honors (list special awards[s] you have received from college and beyond)

Section IV: AREAS OF INTEREST

What type of practice do you engage in or aspire to?
Academic:
Community:
Administrative:
Other:

Section V: CURRICULUM VITAE

* Attach your abbreviated Curriculum Vitae here (only 4-5 pages). CV must be a Word Document with a .doc file extension. The font of the document must be 10 pt with single line spacing. Any other submittal will not be accepted. Max file size is 250 KB.

Section VI: PERSONAL STATEMENT

* Complete a personal statement below, detailing why you want to be a NATF Traveling Fellow, areas of interest, what you will gain from the program, and what you can offer the program. Please state your specific research interests and goals. Statement must contain between 5,000 to 10,000 CHARACTERS in order to be submitted.

Personal Statement

Minimum 5,000 Characters.

August 27, 2008