{"id":15078,"date":"2025-10-15T16:35:16","date_gmt":"2025-10-15T20:35:16","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/care\/?page_id=15078"},"modified":"2025-10-15T16:35:16","modified_gmt":"2025-10-15T20:35:16","slug":"faculty-mentor-application-form","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/care\/faculty-mentor-application-form\/","title":{"rendered":"Faculty Mentor 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_89' style='display:none'>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">25th Annual Chief Resident Immersion Training (CRIT) Program in Addiction Medicine: FACULTY MENTOR Application<\/h3>\n                            <p class='gform_description'><p>Please fill out this application if you are applying to the CRIT Program as a faculty mentor with a chief resident.  <\/p>\r\n\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 statement of support for the chief resident you are applying with (500 words or less), which describes a) how attending the program with your chief resident will enhance their ability to implement addiction medicine curriculum, including completion of a Substance Use Teaching Project (developed at CRIT) and b) how your current faculty position will enable you to add addiction medicine content into the residency program curriculum. <b>Note:<\/b> This statement will serve as the letter of support for your chief resident\u2019s application.<\/p>\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_89'  action='\/care\/wp-json\/wp\/v2\/pages\/15078' data-formid='89' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_89' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_89_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_89_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_89_1'>\n                            \n                            <span id='input_89_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_89_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_89_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_89_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_89_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_89_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_89_2\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_2\"><label class='gfield_label gform-field-label' for='input_89_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_89_2' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_19\"><label class='gfield_label gform-field-label' for='input_89_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_89_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_8\"><label class='gfield_label gform-field-label' for='input_89_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_89_8' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_89_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_89_27\"><label class='gfield_label gform-field-label' for='input_89_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_89_27' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_31\"><label class='gfield_label gform-field-label' for='input_89_31' >Preferred email for CRIT 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_89_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_89_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_89_9\"><label class='gfield_label gform-field-label' for='input_89_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_89_9' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_89_4\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_4\"><h2 class=\"gsection_title\">Residency Program Address<\/h2><\/li><li id=\"field_89_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_89_5\"><label class='gfield_label gform-field-label' for='input_89_5' >Residency program 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_89_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_6\"><label class='gfield_label gform-field-label' for='input_89_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_89_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_32\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_32\"><label class='gfield_label gform-field-label' for='input_89_32' >Total number of residents in your residency program:<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_89_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Residency program 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_89_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_89_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_89_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_89_7_1' id='input_89_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_89_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_89_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_89_7_2' id='input_89_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_89_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_89_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_89_7_3' id='input_89_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_89_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_89_7_4' value=''      aria-required='true'    \/>\n                                        <label for='input_89_7_4' id='input_89_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_89_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_89_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_89_7_5' id='input_89_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_89_7_6_container' >\n                                        <select name='input_7.6' id='input_89_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_89_7_6' id='input_89_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_89_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_89_28\"><label class='gfield_label gform-field-label' for='input_89_28' >Residency program 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_89_28' type='text' value='' class='medium'  aria-describedby=\"gfield_description_89_28\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_89_28'>Write N\/A if there is none.<\/div><\/li><li id=\"field_89_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_89_30\"><label class='gfield_label gform-field-label' for='input_89_30' >Residency program 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_89_30' type='text' value='' class='medium'  aria-describedby=\"gfield_description_89_30\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_89_30'>Write N\/A if there is none.<\/div><\/li><li id=\"field_89_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_89_49\"><label class='gfield_label gform-field-label' for='input_89_49' >Residency program director 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_49' id='input_89_49' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_50\"><label class='gfield_label gform-field-label' for='input_89_50' >Residency program director 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_50' id='input_89_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_18\"><label class='gfield_label gform-field-label' for='input_89_18' >Present 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_89_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_61\"  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_89_61\"><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_89_61'><li class='gchoice gchoice_89_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Instructor'  id='choice_89_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_61_1' id='label_89_61_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_89_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Assistant Professor'  id='choice_89_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_61_2' id='label_89_61_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_89_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Associate Professor'  id='choice_89_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_61_3' id='label_89_61_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_89_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Professor'  id='choice_89_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_61_4' id='label_89_61_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_89_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Other'  id='choice_89_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_61_5' id='label_89_61_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_89_61_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.6' type='checkbox'  value='None'  id='choice_89_61_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_61_6' id='label_89_61_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_89_62\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_62\"><label class='gfield_label gform-field-label' for='input_89_62' >If &quot;Other&quot;- please specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_89_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_24\"><label class='gfield_label gform-field-label' for='input_89_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_89_24' type='text' value='' class='medium'  aria-describedby=\"gfield_description_89_24\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_89_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_89_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_89_48\"><label class='gfield_label gform-field-label' for='input_89_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_89_48' type='text'    value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_89_48 gfield_description_89_48\" \/><div class='gfield_description instruction ' id='gfield_instruction_89_48'>Please enter a number from <strong>0<\/strong> to <strong>100<\/strong>.<\/div><\/div><div class='gfield_description' id='gfield_description_89_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_89_11\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_11\"><h2 class=\"gsection_title\">Mailing Address<\/h2><\/li><li id=\"field_89_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_89_13\"><label class='gfield_label gform-field-label'  >Same as residency program 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_89_13'>\n\t\t\t<li class='gchoice gchoice_89_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_89_13_0'    \/>\n\t\t\t\t<label for='choice_89_13_0' id='label_89_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_89_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_89_13_1'    \/>\n\t\t\t\t<label for='choice_89_13_1' id='label_89_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_89_12\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_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_89_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_89_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_89_12_1' value=''    aria-required='false'    \/>\n                                        <label for='input_89_12_1' id='input_89_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_89_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_89_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_89_12_2' id='input_89_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_89_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_89_12_3' value=''    aria-required='false'    \/>\n                                    <label for='input_89_12_3' id='input_89_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_89_12_4_container' >\n                                        <input type='text' name='input_12.4' id='input_89_12_4' value=''      aria-required='false'    \/>\n                                        <label for='input_89_12_4' id='input_89_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_89_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_89_12_5' value=''    aria-required='false'    \/>\n                                    <label for='input_89_12_5' id='input_89_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_89_12_6_container' >\n                                        <select name='input_12.6' id='input_89_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_89_12_6' id='input_89_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_89_14\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_14\"><h2 class=\"gsection_title\">Other Information<\/h2><\/li><li id=\"field_89_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_89_15\"><label class='gfield_label gform-field-label' for='input_89_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_89_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_89_34\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_34\"><label class='gfield_label gform-field-label' for='input_89_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_89_34' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_52\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_52\"><label class='gfield_label gform-field-label' for='input_89_52' >Pronouns<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_89_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_89_53\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_53\"><label class='gfield_label gform-field-label' for='input_89_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_89_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_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_89_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_89_23'><li class='gchoice gchoice_89_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_89_23_1'   aria-describedby=\"gfield_description_89_23\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_1' id='label_89_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_89_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_89_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_2' id='label_89_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_89_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_89_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_3' id='label_89_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_89_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_89_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_4' id='label_89_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_89_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_89_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_5' id='label_89_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_89_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_89_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_6' id='label_89_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_89_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_89_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_23_7' id='label_89_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_89_23'>Select all that apply.<\/div><\/li><li id=\"field_89_26\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_26\"><label class='gfield_label gform-field-label' for='input_89_26' >Please describe &quot;other&quot;:<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_89_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_59\"  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_89_59\"><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_89_59'><li class='gchoice gchoice_89_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)'  id='choice_89_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_59_1' id='label_89_59_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_89_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='A substance use treatment facility only (e.g., detox, methadone maintenance)'  id='choice_89_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_59_2' id='label_89_59_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_89_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='A harm reduction program (e.g., syringe service, naloxone distribution)'  id='choice_89_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_89_59_3' id='label_89_59_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_89_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_89_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_89_47'>\n\t\t\t<li class='gchoice gchoice_89_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s x-small'  id='choice_89_47_0'    \/>\n\t\t\t\t<label for='choice_89_47_0' id='label_89_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_89_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s small'  id='choice_89_47_1'    \/>\n\t\t\t\t<label for='choice_89_47_1' id='label_89_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_89_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s medium'  id='choice_89_47_2'    \/>\n\t\t\t\t<label for='choice_89_47_2' id='label_89_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_89_47_3'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s large'  id='choice_89_47_3'    \/>\n\t\t\t\t<label for='choice_89_47_3' id='label_89_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_89_47_4'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s x-large'  id='choice_89_47_4'    \/>\n\t\t\t\t<label for='choice_89_47_4' id='label_89_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_89_47_5'>\n\t\t\t\t<input name='input_47' type='radio' value='Men&#039;s xx-large'  id='choice_89_47_5'    \/>\n\t\t\t\t<label for='choice_89_47_5' id='label_89_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_89_47_6'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s small'  id='choice_89_47_6'    \/>\n\t\t\t\t<label for='choice_89_47_6' id='label_89_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_89_47_7'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s medium'  id='choice_89_47_7'    \/>\n\t\t\t\t<label for='choice_89_47_7' id='label_89_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_89_47_8'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s large'  id='choice_89_47_8'    \/>\n\t\t\t\t<label for='choice_89_47_8' id='label_89_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_89_47_9'>\n\t\t\t\t<input name='input_47' type='radio' value='Women&#039;s x-large'  id='choice_89_47_9'    \/>\n\t\t\t\t<label for='choice_89_47_9' id='label_89_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_89_36\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_36\"><h2 class=\"gsection_title\">Faculty Mentor Questions<\/h2><\/li><li id=\"field_89_3\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_3\"><label class='gfield_label gform-field-label' for='input_89_3' >Name of chief resident you are applying with:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_89_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_89_63\"  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_89_63\"><label class='gfield_label gform-field-label' for='input_89_63' >Please give a statement of support for the chief resident you are applying with (500 words or less), including: 1)  How attending the CRIT Program with your chief resident will enhance their ability to implement addiction medicine curriculum in your residency program, including completion of a Substance Use Teaching Project (developed at CRIT), and 2) how your current faculty position will enable you to add addiction medicine content into the residency program curriculum. Please 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_63' id='input_89_63' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_89_43\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_89_43\"><h2 class=\"gsection_title\">Curriculum Vitae<\/h2><\/li><li id=\"field_89_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_89_22\"><label class='gfield_label gform-field-label' for='input_89_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_89_22' type='file' class='medium' aria-describedby=\"gfield_upload_rules_89_22\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_89_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_89_22'><\/div><\/div><\/li><li id=\"field_89_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_89_29\"><label class='gfield_label 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