{"id":15072,"date":"2025-10-15T15:01:20","date_gmt":"2025-10-15T19:01:20","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/care\/?page_id=15072"},"modified":"2025-10-15T15:01:20","modified_gmt":"2025-10-15T19:01:20","slug":"care-faculty-scholars-application-form","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/care\/care-faculty-scholars-application-form\/","title":{"rendered":"CARE Faculty Scholars Application Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_88' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">4th Annual CARE Faculty Scholars (CFS) Program Application<\/h3>\n                            <p class='gform_description'><PALIGN=left>Please fill out this application if you are applying to the CARE Faculty Scholars Program.  \r\n \r\n<p>To complete the application process, we require: \r\n<p><b>1)<\/b> A CV\r\n<p><b>2)<\/b> A personal statement of no more than 500 words that includes your motivation for participating in the program and your plans for creating an addiction medicine curriculum; and \r\n<p><b>3)<\/b> A letter of nomination from your division chief, dean, or program director that emphasizes how the institution will facilitate the dissemination and sustainability of an addiction medicine curriculum \r\n\r\n<p> If you experience any issues while filling out this application, please contact Senior Program Manager Jules Canfield at <b>Jules.Canfield@bmc.org<\/b>.<\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_88'  action='\/care\/wp-json\/wp\/v2\/pages\/15072' data-formid='88' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_88' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_88_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_88_1'>\n                            \n                            <span id='input_88_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_88_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_88_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_88_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_88_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_88_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_88_2\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_2\"><label class='gfield_label gform-field-label' for='input_88_2' >Preferred first name\/nickname (as you would like it on your badge should you be accepted to the program):<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_88_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_19\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_19\"><label class='gfield_label gform-field-label' for='input_88_19' >Degree(s) earned (e.g., MD, MPH):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_88_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_8\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_8\"><label class='gfield_label gform-field-label' for='input_88_8' >Institutional\/work email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_88_8' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_88_27\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_27\"><label class='gfield_label gform-field-label' for='input_88_27' >Personal email:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_88_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_31\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_31\"><label class='gfield_label gform-field-label' for='input_88_31' >Preferred email for program communications:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_88_31' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Institutional email' >Institutional email<\/option><option value='Personal email' >Personal email<\/option><\/select><\/div><\/li><li id=\"field_88_9\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_9\"><label class='gfield_label gform-field-label' for='input_88_9' >Personal telephone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_88_9' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_88_4\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_4\"><h2 class=\"gsection_title\">Institution Address<\/h2><\/li><li id=\"field_88_5\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_5\"><label class='gfield_label gform-field-label' for='input_88_5' >Residency program\/medical school name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_88_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_6\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_6\"><label class='gfield_label gform-field-label' for='input_88_6' >Specialty (i.e., internal medicine, family medicine, other - please explain):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_88_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_7\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Institution address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_88_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_88_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_88_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_88_7_1' id='input_88_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_88_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_88_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_88_7_2' id='input_88_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_88_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_88_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_88_7_3' id='input_88_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_88_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_88_7_4' value=''      aria-required='true'    \/>\n                                        <label for='input_88_7_4' id='input_88_7_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_88_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_88_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_88_7_5' id='input_88_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_88_7_6_container' >\n                                        <select name='input_7.6' id='input_88_7_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_88_7_6' id='input_88_7_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_88_28\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_28\"><label class='gfield_label gform-field-label' for='input_88_28' >Medical school affiliation, if any:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_88_28' type='text' value='' class='medium'  aria-describedby=\"gfield_description_88_28\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_88_28'>Write N\/A if there is none.<\/div><\/li><li id=\"field_88_30\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_30\"><label class='gfield_label gform-field-label' for='input_88_30' >Hospital affiliation, if any:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_88_30' type='text' value='' class='medium'  aria-describedby=\"gfield_description_88_30\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_88_30'>Write N\/A if there is none.<\/div><\/li><li id=\"field_88_49\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_49\"><label class='gfield_label gform-field-label' for='input_88_49' >Name of person who will write your letter of support (i.e, your Division Chief\/Program Director\/Department Chair):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_88_49' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_50\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_50\"><label class='gfield_label gform-field-label' for='input_88_50' >Email of person who will write your letter of support:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_88_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_18\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_18\"><label class='gfield_label gform-field-label' for='input_88_18' >Current faculty position:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_88_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_63\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_63\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Current academic rank<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_88_63'><li class='gchoice gchoice_88_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Instructor'  id='choice_88_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_1' id='label_88_63_1' class='gform-field-label gform-field-label--type-inline'>Instructor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Assistant Professor'  id='choice_88_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_2' id='label_88_63_2' class='gform-field-label gform-field-label--type-inline'>Assistant Professor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_63_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.3' type='checkbox'  value='Associate Professor'  id='choice_88_63_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_3' id='label_88_63_3' class='gform-field-label gform-field-label--type-inline'>Associate Professor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_63_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.4' type='checkbox'  value='Professor'  id='choice_88_63_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_4' id='label_88_63_4' class='gform-field-label gform-field-label--type-inline'>Professor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_63_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.5' type='checkbox'  value='Other'  id='choice_88_63_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_5' id='label_88_63_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_63_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.6' type='checkbox'  value='None'  id='choice_88_63_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_63_6' id='label_88_63_6' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_88_64\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_64\"><label class='gfield_label gform-field-label' for='input_88_64' >If &quot;Other&quot;- Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_88_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_24\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_24\"><label class='gfield_label gform-field-label' for='input_88_24' >Number of years as faculty at your institution:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_88_24' type='text' value='' class='medium'  aria-describedby=\"gfield_description_88_24\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_88_24'>Please enter a number. Junior faculty should have at least one and less than ten years of experience as faculty.<\/div><\/li><li id=\"field_88_48\"  class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_48\"><label class='gfield_label gform-field-label' for='input_88_48' >Percentage of time teaching:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_48' id='input_88_48' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_88_48 gfield_description_88_48\" \/><div class='gfield_description instruction ' id='gfield_instruction_88_48'>Please enter a number from <strong>0<\/strong> to <strong>100<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_88_48'>Please approximate the percentage of time you spend teaching. Enter a number from 0 to 100; do not use a percent sign. <\/div><\/li><li id=\"field_88_11\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_11\"><h2 class=\"gsection_title\">Mailing Address<\/h2><\/li><li id=\"field_88_13\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_13\"><label class='gfield_label gform-field-label'  >Same as institution mailing address above?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_88_13'>\n\t\t\t<li class='gchoice gchoice_88_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_88_13_0'    \/>\n\t\t\t\t<label for='choice_88_13_0' id='label_88_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_88_13_1'    \/>\n\t\t\t\t<label for='choice_88_13_1' id='label_88_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_88_12\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_12\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Mailing Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_88_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_88_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_88_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_88_12_1' id='input_88_12_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_88_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_88_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_88_12_2' id='input_88_12_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_88_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_88_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_88_12_3' id='input_88_12_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_88_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_88_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_88_12_4' id='input_88_12_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_88_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_88_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_88_12_5' id='input_88_12_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_88_12_6_container' >\n                                        <select name='input_12.6' id='input_88_12_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_88_12_6' id='input_88_12_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_88_14\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_14\"><h2 class=\"gsection_title\">Other Information<\/h2><\/li><li id=\"field_88_15\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_15\"><label class='gfield_label gform-field-label' for='input_88_15' >Gender identity:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_88_15' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Prefer to self describe' >Prefer to self describe<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/li><li id=\"field_88_34\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_34\"><label class='gfield_label gform-field-label' for='input_88_34' >If you selected &quot;Prefer to self describe,&quot; please specify here:<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_88_34' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_52\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_52\"><label class='gfield_label gform-field-label' for='input_88_52' >Pronouns<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_88_52' class='medium gfield_select'     aria-invalid=\"false\" ><option value='She\/her' >She\/her<\/option><option value='He\/him' >He\/him<\/option><option value='They\/them' >They\/them<\/option><option value='Prefer to self describe' >Prefer to self describe<\/option><\/select><\/div><\/li><li id=\"field_88_53\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_53\"><label class='gfield_label gform-field-label' for='input_88_53' >If you selected &quot;Prefer to self describe,&quot; please specify here:<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_88_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_23\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_23\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Race\/ethnicity :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_88_23'><li class='gchoice gchoice_88_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Black or African American'  id='choice_88_23_1'   aria-describedby=\"gfield_description_88_23\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_1' id='label_88_23_1' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='American Indian or Alaska Native'  id='choice_88_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_2' id='label_88_23_2' class='gform-field-label gform-field-label--type-inline'>American Indian or Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Asian'  id='choice_88_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_3' id='label_88_23_3' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Hispanic or Latino'  id='choice_88_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_4' id='label_88_23_4' class='gform-field-label gform-field-label--type-inline'>Hispanic or Latino<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Native Hawaiian or Other Pacific Islander'  id='choice_88_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_5' id='label_88_23_5' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian or Other Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='White'  id='choice_88_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_6' id='label_88_23_6' class='gform-field-label gform-field-label--type-inline'>White<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='Other'  id='choice_88_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_23_7' id='label_88_23_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_88_23'>Select all that apply.<\/div><\/li><li id=\"field_88_26\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_26\"><label class='gfield_label gform-field-label' for='input_88_26' >Please describe &quot;other&quot;:<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_88_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_88_60\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_60\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Have you ever visited the following in a professional context? (Check all that apply.)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_88_60'><li class='gchoice gchoice_88_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)'  id='choice_88_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_60_1' id='label_88_60_1' class='gform-field-label gform-field-label--type-inline'>A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='A substance use treatment facility only (e.g., detox, methadone maintenance)'  id='choice_88_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_60_2' id='label_88_60_2' class='gform-field-label gform-field-label--type-inline'>A substance use treatment facility only (e.g., detox, methadone maintenance)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='A harm reduction program (e.g., syringe service, naloxone distribution)'  id='choice_88_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_60_3' id='label_88_60_3' class='gform-field-label gform-field-label--type-inline'>A harm reduction program (e.g., syringe service, naloxone distribution)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_88_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_47\"><label class='gfield_label gform-field-label'  >Preferred T-shirt size (should you be accepted to the program):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_88_47'>\n\t\t\t<li class='gchoice gchoice_88_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s x-small'  id='choice_88_47_0'    \/>\n\t\t\t\t<label for='choice_88_47_0' id='label_88_47_0' class='gform-field-label gform-field-label--type-inline'>Men's x-small<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s small'  id='choice_88_47_1'    \/>\n\t\t\t\t<label for='choice_88_47_1' id='label_88_47_1' class='gform-field-label gform-field-label--type-inline'>Men's small<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s medium'  id='choice_88_47_2'    \/>\n\t\t\t\t<label for='choice_88_47_2' id='label_88_47_2' class='gform-field-label gform-field-label--type-inline'>Men's medium<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_3'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s large'  id='choice_88_47_3'    \/>\n\t\t\t\t<label for='choice_88_47_3' id='label_88_47_3' class='gform-field-label gform-field-label--type-inline'>Men's large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_4'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s x-large'  id='choice_88_47_4'    \/>\n\t\t\t\t<label for='choice_88_47_4' id='label_88_47_4' class='gform-field-label gform-field-label--type-inline'>Men's x-large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_5'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s xx-large'  id='choice_88_47_5'    \/>\n\t\t\t\t<label for='choice_88_47_5' id='label_88_47_5' class='gform-field-label gform-field-label--type-inline'>Men's xx-large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_6'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s small'  id='choice_88_47_6'    \/>\n\t\t\t\t<label for='choice_88_47_6' id='label_88_47_6' class='gform-field-label gform-field-label--type-inline'>Women's small<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_7'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s medium'  id='choice_88_47_7'    \/>\n\t\t\t\t<label for='choice_88_47_7' id='label_88_47_7' class='gform-field-label gform-field-label--type-inline'>Women's medium<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_8'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s large'  id='choice_88_47_8'    \/>\n\t\t\t\t<label for='choice_88_47_8' id='label_88_47_8' class='gform-field-label gform-field-label--type-inline'>Women's large<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_88_47_9'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s x-large'  id='choice_88_47_9'    \/>\n\t\t\t\t<label for='choice_88_47_9' id='label_88_47_9' class='gform-field-label gform-field-label--type-inline'>Women's x-large<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_88_61\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_61\"><label class='gfield_label gform-field-label' for='input_88_61' >Please provide a personal statement of 500 words or less that includes your motivation for participating in the program and your plans for creating an addiction medicine curriculum. Copy-paste this into the box below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_88_61' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_88_58\"  class=\"gfield gfield--type-fileupload field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_58\"><label class='gfield_label gform-field-label' for='input_88_58' >Please upload a letter of support from your Division Chief\/Program Director\/Department Chair that emphasizes how the institution will facilitate dissemination and sustainability of an addiction medicine curriculum.<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_58' id='input_88_58' type='file' class='medium' aria-describedby=\"gfield_upload_rules_88_58 gfield_description_88_58\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_88_58'>Accepted file types: doc, docx, pdf, Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_88_58'><\/div><\/div><div class='gfield_description' id='gfield_description_88_58'>If you don't have this ready at the time of application submission please have it emailed to Jules Canfield at jules.canfield@bmc.org prior to the application deadline. <\/div><\/li><li id=\"field_88_43\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_43\"><h2 class=\"gsection_title\">Curriculum Vitae<\/h2><\/li><li id=\"field_88_22\"  class=\"gfield gfield--type-fileupload gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_22\"><label class='gfield_label gform-field-label' for='input_88_22' >Please upload your curriculum vitae (CV) as a PDF here.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_22' id='input_88_22' type='file' class='medium' aria-describedby=\"gfield_upload_rules_88_22\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_88_22'>Accepted file types: doc, pdf, docx, Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_88_22'><\/div><\/div><\/li><li id=\"field_88_29\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_88_29\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >How did you hear about the CARE Faculty Scholars Program?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_88_29'><li class='gchoice gchoice_88_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Previous program attendee'  id='choice_88_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_29_1' id='label_88_29_1' class='gform-field-label gform-field-label--type-inline'>Previous program attendee<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Faculty at my institution'  id='choice_88_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_29_2' id='label_88_29_2' class='gform-field-label gform-field-label--type-inline'>Faculty at my institution<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Brochure or postcard advertising the program'  id='choice_88_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_88_29_3' id='label_88_29_3' class='gform-field-label gform-field-label--type-inline'>Brochure or postcard advertising the program<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_88_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Internet search'  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