American Society for Reconstructive Microsurgery Visiting

Professor Program Request to Host Visiting Professor

Institution & Program Name

Program Director Name

First Name

Last Name

Contact Name

First Name

Last Name

Institution Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone

Country

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###

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Contact Email

Program Website

http://

Order of Preference (if any) of current Visiting Professors

On behalf of the institution and program I confirm that the expenses incurred by the traveling professor including hotel, meals and local transportation that are not covered by the ASRM will be paid by the host institution and/or program.

Program Director Name | e-Signature

Date

MM

DD

YYYY

The ASRM Visiting Professor Program highlights the fantastic work of microsurgeons and ASRM members as well as the diversity associated with a practice involving microsurgery and complex reconstruction. Hosting a visiting professor promotes early exposure of medical students and young surgeons to the field of microsurgery to education and potentially interests them in a career involving microsurgery. ASRM members will be selected to participate in this program each year based on applications received. Visiting Professors will be provided up to $5,000 to cover flight and transportation to and from the host institution. The host institution is responsible for paying the remaining costs including hotel, meals and local transportation. Travels dates are worked out directly between the visiting professor and program. Traveling professors are longstanding and actively participating members of the ASRM. There may be more requests to host an ASRM Traveling Professor than opportunities to travel. If your program does not have the privilege of hosting an ASRM Visiting Professor, we encourage you to submit your interest to host the following year

DUE APRIL 1

American Society for Reconstructive Microsurgery 781 S. Midlothian Rd, Mundelein, IL 60060 / P: 312-456-9579 / E: asrmoffice@gmail.com

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