SUS STORZ Award for Residents, Fellows, Faculty Application

SUS STORZ Award for Residents, Fellows, Faculty

I am applying for this award as a:*
- Resident
- Fellow
- Faculty
I am an SUS member in good standing.
Please note this information will be verified at the time of submission.
- Yes, I am an SUS member in good standing.
- I am not an SUS member.
General Information
Name*
First Last Degree(s)
Primary Email*
Secondary/Alternate Email
Post Grad Year*
If other, enter Post Grad Year
Surgical Specialty:*
Academic Role:*
Institution*
Primary Institution Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Institution Phone Number*
Primary Institution Fax
Primary Institution Department*
Are you doing your research year at another (secondary) institution?*
- Yes
- No
Secondary Institution*
Secondary Institution Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Institution Phone Number*
Secondary Institution Fax
Secondary Institution Department*
Project Title*
Letters of Recommendation
If you are applying as a resident or fellow, you must submit two letters of recommendation; one from your SUS Member Research Mentor, and one from your Department Chair. If you are applying as a faculty member you must submit a letter from your Department Chair ONLY.

1. SUS MEMBER RESEARCH MENTOR: To meet the eligibility requirements, the SUS Member Research Mentor must be a member in good standing. They may check their member status by contacting the SUS Membership Department at membership@susweb.org.

2. DEPARTMENT CHAIR.

Your Research Mentor and Department Chair may be the same person. They must upload two separate letters. In this case, the letter from the Department Chair may be kept short.

Your letter writer will receive a request to upload a letter on your behalf upon submission of your application. Please allow adequate time to allow your letter writers to upload their letters of support prior to the application deadline. Please confirm with your letter writer that they received the email and upload a letter of recommendation by the deadline.
SUS Member Research Mentor Name:*
First Last
SUS Member Research Mentor Email:*
MemberMentorID
DepartmentChairID
Department Chair Name:*
First Last
Department Chair Email*
Supporting Documents
All documents must be submitted in a PDF format. Uploaded supporting documents will NOT BE SAVED if you select Save & Continue. Documents will only be saved upon submission of your application.
Due to the number of files required with large file sizes, submission make take up to three minutes. Do not re-submit or leave the application page once you have clicked submit. You will be directed to a confirmation page once your application has been successfully completed.
Facilities and Resource Document*
Accepted file types: pdf.
Applicant Biosketch*
Accepted file types: pdf.
SUS Member Research Mentor Biosketch*
Accepted file types: pdf.
Research Application Document*
Accepted file types: pdf.
Budget*
Accepted file types: pdf.
Authorization Form*
Click here to download the authorization form.
Accepted file types: pdf.
Phone
This field is for validation purposes and should be left unchanged.

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SUS STORZ Award for Residents, Fellows, Faculty

General Information

Letters of Recommendation

Supporting Documents