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Junior and Early Career Membership Committee Futures Program Application
Junior and Early Career Membership Committee Futures Program Application
"
*
" indicates required fields
Please complete the form below completely and be sure to upload your CV.
The deadline to submit applications is Tuesday, February 25, 2025, 11:59 PM PST
. Only complete applications will be considered. If you have questions about the ANA Futures Program, please contact Nicole Baus at
nbaus@myana.org
.
Name
*
First
Last
Credentials
Email Address
*
Institution
*
Institution City and State
*
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Phone Number (Cell number preferred)
*
Please select your current level:
*
Make a selection
Resident PGY1
Resident PGY2
Resident PGY3
Resident PGY4
Medical Student
Medical Student Applying
Other
Current level – Other
*
Professional Reference Title
*
Professional Reference Email
*
Are you planning to submit an abstract for presentation at ANA2025?
*
Yes
No
Describe your interest in neurology
*
How do you envision your future neurological practice
*
Describe your interest in ANA and the ANA Futures Program, and what role you see them playing in your future career trajectory
*
What unique attributes will you bring to the group
*
Please upload your CV
*
Accepted file types: pdf, Max. file size: 1 MB.
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