American Society of Pediatric Otolaryngology Membership Application

ASPO Mini-Mentorship Application
Thank you for your interest in the ASPO Mini-Mentorship Travel Award. For consideration please complete and submit the following application.

Application Guidelines:
- -Only 1 per residency program per year (must request special waiver from committee if more than 1)
- -Oct 31 deadline for the following Jan-Dec year
- -Ideally PGY3. Exceptions for PGY2 and PGY4 will be made
- -This is not to replace or supplement a normal residency pediatric requirement. This is observership, and cases are not counted towards the case log
Application materials required:
- Completed Application
- Letter of Support from Program Director
- Letter of Support from Residency Director
Name:*

First NameLast Name
Email:*
Phone Number:*

Area CodePhone Number
Pager Number:

Area CodePhone Number
PGY Level:*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Personal statement explaining your desire for further exposure to pediatric otolaryngology (250 words max):*

0/250
Name of your Program Director:*
Letter of Support from your Program Director:*

Upload a File

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Name of your Residency Director:*
Letter of Support from your Residency Director:*

Upload a File

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We look forward to reviewing your application. If you have any questions please contact Liz O'Keefe at aspo@facs.org or 312-202-5005.
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ASPO Mini-Mentorship Application