Scholarship Application Form for CBAM Courses

Full Name:(Required)

First Last

Primary Contact Number:(Required)

Email Address:(Required)

Medical Degree:

Current Workplace (Clinic/Hospital Name):(Required)

Medical License Number:(Required)

Issuing Medical Authority:(Required)

Please upload a document(s) in support of your Medical License, Nursing License, Professional license/certification, or student card (in case of being in aesthetic business)(Required)

Drop files here or

Max. file size: 50 MB.

How do you plan to contribute to the field of aesthetic medicine after certification?(Required)

Program of Desire:(Required)

Board Certified program

CAMP Certified program

Master Injector program

Basic and Advanced Injectables courses

Basic Injectables course

Untitled(Required)

I hereby declare that the information provided in this application is accurate and complete. I understand that any false information may result in disqualification from the scholarship.

Signature(Required)