Resident Program application form Step 1 of 4 – Contact Information 0% Your contact informationName(Required) First Last Email(Required) Please enter an email where you can be reached after graduation, as this will be where information about your free gift is sent.Phone(Required) Residency DetailsTell us about your residency!Medical School of your Plastic Surgery residency(Required)Residency Program ChiefDate of Graduation (from residency)Month(Required)MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear(Required)Year202220232024202520262027* This online application is limited to senior residents. If you are not graduating within 2 years, please contact us with your questions: Contact UsFellowshipsAre you planning to take a fellowship?(Required) Yes No Where will your fellowship be?In what sub-specialty is your fellowship? Shipping Address / Future Practice DetailsShipping Address for your gift** This address will serve as your shipping address for your free scissors. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code If you don't know the address for your shipment yet, please check this box Please contact me close to my graduation date for shipment details Future PracticeWhere will you be practicing post-graduation?Do you know the address of your future practice? Yes No Future Practice Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact PreferenceA Black & Black representative will be glad to assist you with your instrument purchase!What is the best time and date for us to contact you?Preferred contact method Phone Call Email Your Free Gift: SuperCut ScissorsTo express our gratitude for the chance to service your surgical needs for years to come, we would like to offer you a SuperCut scissor of your choice!* *Spring handle, angled, endoscopic, and electrosurgery scissors excluded. Choose your scissors: SuperCut Scissors Then enter your scissors’ item number below.Scissors Product ID(Required)Great choice! Customization: Name for Laser Etching(Required)Please enter up to 20 characters for customizing your gift:** If your name turns out to be longer than possible for etching on your chosen scissor, our office will contact you for an alternative.Privacy notice and ConsentBlack & Black Surgical does not release information from this form to any third party organization. Your information is collected for the purpose of contacting you to assist in purchasing your new practice’s instruments, and for completing the delivery of your free customized surgical scissors. If you wish to no longer be contacted, you can let us know at any time to be removed from our contact list.Consent(Required) I agree to the Residents’ Program terms.I agree to be contacted by Black & Black Surgical regarding this application, and/or the requested scissors gift, using the contact information entered in this form. Thank you for completing this form!CommentsThis field is for validation purposes and should be left unchanged.
