Laughlin Fellowship Nomination

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Laughlin Fellowship Nomination Form

Nominee

Name*
Degree(s)*
PGY*
Date Residency Began*

Nominee Institution

Facility*
University*

Address*

City, State, Zip*
Country*
Work Phone*

Nominee Residence

Address*

City, State, Zip*
Country*
Home Phone*
Mobile Phone*
Email*

Nominator

Name*
Degree(s)*
Title*
Work Phone*
Email*

Required documents

: PDFs only
Personal Statement*
CV/Resume*
Letter of Nomination*: NOTE: Only one letter of nomination will be considered by the current training director or designee

NOTE: Each separately accredited sponsoring institution may submit only one nomination.

NOTE: Candidates may be nominated for either the PRITE or Laughlin Fellowship, not both in the same year. Those selected as a PRITE or Laughlin Fellow may not apply for the other fellowship in future years.

DEADLINE: Applications due by: May 15th of each calendar year