OSNA/COUR INTERNATIONAL SCHOLARSHIP APPLICATION

COUR INTERNATIONAL EDUCATIONAL SCHOLARSHIP APPLICATION DEMOGRAPHICS Date:* Please check degree(s) you hold:*

MD/DO Resident/Physician Orthopedic Surgery Fellow Attending Staff PhD Other

Family Name:* First Name:* Middle/Other Names: Gender:*

Male Female
Address where mail should reach you before and after your scholarship (street address, city, state/province, postal code, country)*

Telephone number (include country code/area code/local number):* E-mail Address:* Country of Citizenship* Country of Birth* Emergency Contact (Name, Relationship, Address, Telephone, Email):*

OUR INTERNATIONAL EDUCATIONAL SCHOLARSHIP APPLICATION DEMOGRAPHICS Date:* Please enter a value. Please check degree(s) you hold:*

MD/DO Resident/Physician Orthopedic Surgery Fellow Attending Staff PhD Other

Please enter a value. Family Name:* Please enter a value. First Name:* Please enter a value. Middle/Other Names: Gender:*

Male Female
Please enter a value. Address where mail should reach you before and after your scholarship (street address, city, state/province, postal code, country)*

Please enter a value. Telephone number (include country code/area code/local number):* Please enter a value. E-mail Address:* Please enter a value. Country of Citizenship* Please enter a value.

Country of Birth* Please enter a value. Emergency Contact (Name, Relationship, Address, Telephone, Email):*

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PERSONAL INFORMATION Educational History (List post-secondary or University Level (include studies planned between now and the upcoming POSNA or IPOS meeting); list planned or most recent studies) Institution Name and Location (Name, City/Town, State/Province, Country)* Dates Attended (Mo/Yr), Field of Study and Degree/Certificate* Institution Name and Location (Name, City/Town, State/Province, Country)* Dates Attended (Mo/Yr), Field of Study and Degree/Certificate* Institution Name and Location (Name, City/Town, State/Province, Country)* Dates Attended (Mo/Yr), Field of Study and Degree/Certificate* Employment History (List Current or most recent first) Name of Employer* Job Title, Position or Type of Work* Dates Worked (List start date to end date (Month/Year))* Name of Employer* Job Title, Position or Type of Work* Dates Worked (List start date to end date (Month/Year))* Name of Employer* Job Title, Position or Type of Work* Dates Worked (List start date to end date (Month/Year))* My airport of departure to the USA is:* Please state how much financial support your current institution, place of employment or other source will provide (USD):

If you have extenuating financial needs, please describe: If you have extenuating financial needs, please describe:

State/Provice; Country Dates; Duration of Stay (Months); Reason

Previous Experiences Outside Your Home Country (Please list the countries in which you have previously lived or studied, as pertaining to your current profession, for more than one month.) State/Provice; Country Dates; Duration of Stay (Months); Reason

State/Provice; Country Dates; Duration of Stay (Months); Reason

Please list any POSNA, IPOS or AAOS meetings and dates you have attended for the last 5 years.

Pease write a detailed statement of your intent, describing the following: -Your reason for applying for the COUR scholarship-How you propose to implement any new knowledge obtained into your current practice and share the information with others-Career objectives-Teaching experience