Stepstone Fellowship Application Applicant InformationName(Required) First Last GenderFemaleMaleTransgenderNon-binaryRace/EthnicityWhiteBlack or African AmericanHispanic or LatinoAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderTwo or more racesOther, not listed herePhone(Required)Email(Required) Institution(Required)DepartmentInstitution Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Active member of the militaryYesNoGeneral area of surgeryArea of researchSurgical discipline*write N/A if you do not want to provideQualifications -Must be a SUS Member in the first five years -Ability to travel to another institution for a period of one week -Confirmation from fellow's institution for ability to travel and additional financial support -Ability to accept award at SUS annual awards session at ASC Are you an SUS member in the first five (5) years of membership?(Required) Yes No What year did you become an SUS member?(Required)Please confirm your institution's ability to allow travel and additional financial support(Required) Yes No Are you able to travel to another institution for a period of up to one week?(Required) Yes No Are you able to attend the SUS annual awards session at ASC to accept your award?(Required) Yes No Name of visiting faculty sponsor(Required)Describe your plans for this fellowship(Required)Any other extramural sourcesApplicationCover Letter(Required)Max. file size: 512 MB.Outlining development plan, short/long term career goals, plans for interacting with mentorLetter of support from the Mentor(Required)Max. file size: 512 MB.Letter of support from you current Chair(Required)Max. file size: 512 MB.Letter of Recommendation from SUS Member(Required)Max. file size: 512 MB.Letter of recommendation from SUS Member(Required)Max. file size: 512 MB.Personal Statement(Required)Please include a personal statement that outlines your qualifications, plans for the fellowship and ways this experience will contribute to your career goals. CV(Required)Max. file size: 512 MB.Biosketch(Required)Max. file size: 512 MB.Current photo(Required)Max. file size: 512 MB.If you have any questions or require additional information regarding the application, please contact Gina Hardiman at [email protected]List Add Remove
