Scholarship/Grant Application Form

Scholarships and grants are available for residents or practicing members seeking to engage in charity or research endeavors. The AOCOO-HNS Foundation promotes extracurricular activities for all members for the advancement of our specialties, as well as for assisting those patients in need. The proposed intent for the grant must be detailed within the application.

Contact Information

First Name

Middle Name

Last Name

Maiden Names

Phone

Birthdate

Country

Address

Apt/Bld/Suite

City

State

Postal Code

College

College Attended

List extracurricular activities during college

Honors received

Medical School

Year of Graduation

List Extracurricular Activities During Medical School

Honors Received

Name and Address of Your Chairman of Department of Your Training Institution

Residency

Residency Program

Year of Completion

If the Applicant is Still in Residency Training, Indicate if Resident Annual Reports are Current

Yes

List Special Training, Honors, Research, Publications, etc

Are You Eligible to be Certified by the AOBOO Specialty Board?

Yes

Scholarship/Grant Request File or Description

Write Description Here or Attach File Below

Scholarship/Grant Request File

Drop files here or click to upload.

Upload file or write in box above

Terms and Conditions

I understand that if my application is accepted and I am given this grant, I will be responsible for my own actions and further agree to release and hold harmless the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery Foundation, Inc., their agents and employees from any damages, liabilities or expenses they incur by reason of my actions of whatever nature or kind in connection with this award. I agree to fully accept responsibility for all personal insurance I deem necessary should I receive this grant.

I Accept

Address application and questions to:
Ralph McClish
AOCOO-HNS Foundation, Inc.
3200 Carlisle Blvd NE, Ste 225
Albuquerque, NM 87110
phone 855.262.6646
e-mail ralph@aocoohns.org