AAS/AASF Henri Ford Award Application Step 1 of 3 33% Name* First Last Email* Gender* Female Male Transgender Female Transgender Male Gender Variant/Non-conforming Prefer not to answer Race/Ethnicity* American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian AAS Membership Status*Note: You must be a member to submit an application. Membership will be verified. If your membership application is currently under review, you are still eligible to apply. I am an Active Member I have an application in process Surgical Status* Fellow Instructor Assistant Professor Are you an active member of the military?* Yes No Institution* Department* Address* 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 Phone*In the case we need to reach you regarding your submissionPlease indicate your general area of academic surgery:* Basic Science/Translational Research Clinical Outcomes/Health Services/Education Area of Research Surgical Ethics Education Epidemiology Biostatistics Health Care Delivery Surgical Discipline(s)* Acute Care Surgery Bariatric Cardiothoracic Colorectal Critical Care Endocrine General Surgery GI/HPB Minimally Invasive Pediatric Surgery Plastics Surgical Oncology Transplant Trauma Vascular Other Proposal Title* Mentor Name* First Last Mentor AAS Membership Status*There must be at least one mentor who is an active or senior member of the AAS Member Not a Member Has this proposal been or will be submitted to other extramural funding sources?* No/None NIH VA Medical Institution Department Funds Other Supporting DocumentsALL DOCUMENTS MUST BE UPLOADED AS ONE FILE IN PDF FORMAT (REQUIRED). Grants which are incomplete or do not follow the page limits or formatting guidelines will not be reviewed. Applicants submit the following materials: Cover Letter (Limit: 1 page) - Must outline your career development plan, short and long-term career goals, and plans for interacting with their mentors/collaborators NIH-style Biosketch (Limit: 5 pages) Comprehensive Research Plan (Limit: 5 pages) single-spaced, Arial 11pt, 1" margin, excluding references. Must include: abstract for research proposal significance of research background information preliminary observations experimental plan (methods, materials, potential limitations and pitfalls) Budget (Limit: 1 page) - Brief budget justification. Must include 10% use for travel (see funding parameters listed above) Letter from Sponsoring Research Mentor (Limit: 2 pages) Letter of Support from the Chair of your Department (Limit: 2 pages) - The letter should also state that the award will not be used for salary support for the recipient Applications which exceed the page limitations WILL NOT BE REVIEWED.Upload*Accepted file types: pdf, Max. file size: 512 MB.Due to the large file size, 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. NOTE: YOUR UPLOAD WILL NOT SAVE IF YOU SELECT 'SAVE AND CONTINUE'EmailThis field is for validation purposes and should be left unchanged. Share this:TwitterFacebookLinkedInPrint