<p> Multiple Sclerosis Clinical Care Physician Fellowships Program Sponsored by the National Multiple Sclerosis Society</p><p>Application Instructions & Form</p><p>(Note: We are in the process of converting to an on-line application system. Please consult www.nationalmssociety.org/PRC.asp prior to submitting an application.)</p><p> The deadline for receipt of a completed application is September 14, 2007 for the award to become effective July 1, 2008.</p><p> SEVEN copies (original and 6 copies) of the application must be submitted. </p><p> Do not staple the sets, but secure them with rubber bands or paper clips.</p><p> You must submit the application in hard-copy (paper) form. Electronic submissions will not be accepted.</p><p> All items of the application form must be completed.</p><p> Do not make any changes in the layout of the forms; use single-spaced format and stay within the margin limitations indicated. </p><p> Use standard size black type (no smaller than 11 point) that can be photocopied; do not use photoreduction. </p><p> Seven copies of any preprints, reprints, or other additional materials must be submitted with the application. </p><p> The application must be submitted accompanied by all supporting documents. Please do not submit your application until you have assembled all references, transcripts and other requested materials. </p><p>- Letters of Recommendation: The letters should include one from the chairperson of your department or residency director. Request that your referees give you an original letter and 6 copies in a SEALED envelope. Submit the sealed envelopes with your application. Do NOT request that the referee send the letter directly to the NMSS. - Academic Transcripts: Academic transcripts from medical schools are required. If an institution does not permit issuance of transcripts to you, ask the registrar to send such transcripts directly to the National MS Society, prior to the deadline for receipt of the application. It is preferable, however, that the transcripts accompany your application. Photocopies are acceptable.</p><p> The application cannot be considered for review unless signed by the applicant, the mentor, the financial officer, and the relevant official of the sponsoring institution. “Per” signatures will be disallowed.</p><p> The application and all correspondence relating to it must be received at the Society by September 14, 2007. Please send to: National Multiple Sclerosis Society 733 Third Avenue, New York, NY 10017-3288 Attn: Alicia Soto</p><p>If you have any questions about the preparation of your application, please contact Alicia Soto at the NMSS by telephone: (212) 476-0457 or by email: [email protected] National Multiple Sclerosis Society (NMSS Use Only) 733 Third Avenue July 1, 2008-June 30, 2009 New York, NY 10017-3288 Application Number: (212) 986-3240</p><p>MS CLINICAL CARE PHYSICIAN FELLOWSHIPS APPLICATION</p><p>Name of Applicant</p><p>Last Middle First </p><p>Degrees </p><p>Home Address of Applicant</p><p>Street </p><p>City State Zip Code - </p><p>Home Telephone ( ) - Home Fax ( ) - </p><p>Work Telephone ( ) - Work Fax ( ) - </p><p>E-mail address </p><p>If you cannot be reached at this address through February 2008, please provide an alternative address and expected date of occupancy.</p><p>Street Date of occupancy / / </p><p>City State Zip Code - </p><p>Telephone ( ) - ex: Fax ( ) - </p><p>E-mail address </p><p>Name of Mentor</p><p>Last Middle First </p><p>Degrees </p><p>Address of Mentor</p><p>Institution Street </p><p>City State Zip Code - </p><p>Telephone ( ) - ex: Fax ( ) - </p><p>E-mail address Applicant Name:</p><p>Name of Proposed Training Institution</p><p>Institution </p><p>Department </p><p>Address of Proposed Training Institution</p><p>Street </p><p>City State Zip Code - </p><p>Telephone ( ) - Fax ( ) - </p><p>E-mail address </p><p>Name and Address of Institution’s Financial Officer</p><p>Name </p><p>Department </p><p>Institution </p><p>Street </p><p>City State Zip Code - </p><p>Telephone ( ) - Fax ( ) - </p><p>E-mail address</p><p>Name and Address of Department Chair</p><p>Name </p><p>Department </p><p>Institution </p><p>Street </p><p>City State Zip Code - </p><p>Telephone ( ) - Fax ( ) - </p><p>E-mail address </p><p>Make Award Check Payable to: Applicant Name:</p><p>Proposed Budget</p><p>The fellowship award is $65,000, payable to the institution on a quarterly basis, to cover the fellow's salary, fringe benefits, and institutional costs. The National Multiple Sclerosis Society will make four equal payments of $16,250 to the institution, in July 2008, October 2008, January 2009, and April 2009. Please have the financial officer of the institution complete the following budget table for the fellowship year.</p><p>Category Amount Salary for fellow </p><p>Fringe benefits package (Please itemize and list associated costs.) </p><p>Institutional costs. Note: This may not exceed 10% of the award ($6,500). </p><p>Other (Please itemize and list associated costs.) </p><p>TOTAL $65,000 Additional support provided to awardee by institution (if applicable) </p><p>Comments:</p><p>Applicant Name:</p><p>Biographical Sketch of Applicant Education (include undergraduate, graduate/medical school, internship and residency) Name and Location of Institution Inclusive Dates Degrees Earned</p><p>Academic Honors (include dates)</p><p>Professional Experience (begin with most recent position) Position Employer Name and Location Inclusive Dates </p><p>Applicant Name:</p><p>Memberships in Professional Organizations</p><p>Applicant Name:</p><p>Applicant’s Bibliographic Citations Include complete reference and list in chronological order. Please limit to one page.</p><p>Applicant Name:</p><p>Personal Statement Describe your long and short-term career goals. Discuss how the fellowship will advance these goals. Describe your personal qualifications for this award. (Please limit to one page).</p><p>Applicant Name:</p><p>Training Plan Using the following outline, describe the training plan that you and your mentor have developed to meet the required components of training. Please limit to two pages.</p><p>Components of Training: 1. Direct, supervised MS patient care (65%) 2. Exposure to multidisciplinary care (20%) 3. Didactic activities (15% - including producing a clinical paper, attending lectures, grand rounds, etc.) 4. Other</p><p>Applicant Name:</p><p>Training Plan (continued)</p><p>Applicant Name:</p><p>Recommendations and Transcripts</p><p>The following documents MUST accompany this application:</p><p>A. Three (3) letters of recommendation. Attach in original sealed envelopes.</p><p>Name/Title Mailing Address/Telephone</p><p>1. </p><p>2. </p><p>3. </p><p>B. Medical School Transcripts: Must be attached to this application. Originals or photocopies are acceptable.</p><p>Name of Institution Address</p><p>Applicant Name:</p><p>INFORMATION TO BE PROVIDED BY MENTOR (Note: Mentor may attach a CV if it addresses the information requested below.) Name of Mentor Position/Title</p><p>Education Institution and Location Degree Year Conferred</p><p>Professional Experience: List in chronological order previous employment, experience, honors. Please limit to two pages.</p><p>Applicant Name:</p><p>Professional Experience (continued)</p><p>Applicant Name:</p><p>Mentor’s Bibliographic Citations</p><p>Include complete reference and list in chronological order. Please limit to one page. Bibliography can be selected if necessary.</p><p>Applicant Name:</p><p>Letter of Support from Mentor</p><p>The mentor must provide the following information. The mentor letter must be attached to this page.</p><p>1. A description of the ongoing clinical activities at the MS clinic or practice. 2. A description of the multidisciplinary care team. 3. A description of any previous or current fellowship/trainees in the past 5 years. 4. An evaluation of the likelihood that the applicant will make a meaningful contribution to MS as a clinician after the fellowship training. Applicant Name:</p><p>Applicant’s full name and degree(s) (NMSS use only) Application number</p><p>CERTIFICATE OF APPLICANT AND SPONSORING INSTITUTION</p><p>By the act of submitting an application for an award, it is agreed by the Applicant and the Institution that: 1) Funds awarded as a result of this request are to be expended for the purpose(s) set forth herein and in accordance with the policies and procedures set forth by the National Multiple Sclerosis Society [the Society]; 2) The information herein is true and complete to the best of our knowledge; 3) The Award may be revoked in whole or in part at any time by the Society, provided that a revocation shall not include any amount obligated previous to the effective date of revocation if such obligation were made solely for the purposes set forth in this application; 4) All reports of activities supported by any award made as a result of this request shall acknowledge such support. Name Signature Date Office Telephone No. Applicant / / ( ) - </p><p>Mentor / / ( ) - </p><p>Financial Officer / / ( ) - </p><p>Official Authorized to Sign for Institution [include official’s title]</p><p>/ / ( ) - </p>