100%

he be chosen as a scholar.

Questions marked with a * are required

Applicant Information:

First Name

Last Name

Phone (Including Country Code)

Email Address

Complete Office Address of Applicant

Website (if any)

Country

WONCA Region

Information about WONCA meeting that is relevant to this application:

Dates

Name of Meeting

Location

Other Pertinent Information

Type of Practice:
(Note: Please specify the approximate percentage devoted to each type of practice.)

Clinical

Research

Teaching

Administration

Other (specify)

Please list two professional references and their contact information below (the applicant should obtain prior approval to use a reference and inform him or her that someone from the regional Wonca office will be contacting them for the reference).

Please note here how you heard about this scholarship:

Please provide a brief statement of several interests/reasons that motivated you to apply for the Montegut Scholarship (no more than one hundred words (100) words :

Brief statement of your financial need for scholarship (in general terms, not specific financial statements):

An updated, current curriculum vitae is attached to this application (minimum information should include medical educational background, community service, honors, etc.). If you are unable to upload your CV here, please send it via email to secretariat@wonca.net referencing MONTEGUT/YOUR NAME in the subject.

Introduce yourself and describe how the Montegut Scholarship will contribute to your career advancement in a video presentation, not exceeding two minutes.
If you are unable to upload your Video here, please send it via email to secretariat@wonca.net referencing MONTEGUT/YOUR NAME in the subject.

I commit to engaging in interviews and various promotional activities with WONCA and ABFM, dedicated to disseminating their experiences associated with the Montegut scholarship. This includes granting permission for the distribution of these materials on diverse channels such as the website and newsletter.

I have read, understand and agree to the terms of the ‘policy and procedures’ of the ABFM Foundation’s Montegut Global Scholars Program attached to this application.

Applicant Signature

Clear

Date of Application: