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Application Information:
Application for NIH/Pharmacological Sciences Predoctoral Fellowship
2017/2018
Due Monday, May 22, 2017
Please be prepared to complete this application in one session. The software does not allow
for easy retrieval of information that was entered on another computer or another login. You
may have to start over if you do not complete the application. We have provided a PDF
version of the application on the website so that you can prepare your answers ahead of
time.
*indicates a REQUIRED response is needed. The software may not let you proceed without
answering these questions.
Applicant Information:
*Name (last, first, m.i.):
*Campus Address:
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*Contact information:
Work
Mobile
Home
Birth Date (mm/dd/yyyy) and Birth Place:
mm/dd/yyyy
city, state, country
*Citizenship Status: (An F-1 visa is not an eligible status)
U.S. Citizen or Noncitizen National
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Non-U.S. Citizen / With a Permanent U.S. Resident Visa ("Green Card")
In not a U.S. citizen, of which country are you a citizen?
*Ethnic Status:
Hispanic or Latino
Not Hispanic or Latino
*Race:
American Indian or Alaskan Native (specify tribal/nation affiliation)
Native Hawaiian or other Pacific Islander
Asian
Black or African American
White
Do you have a disability?
Yes
No
Do not wish to provide
If yes, which of the following categories describe your disability(ies):
Hearing
Visual
Mobility/orthopedic Impairment
Other
Are you from a disadvantaged background?
Yes
No
Intentionally withheld
University of Iowa Affiliation: (*send or attach copy of current UI transcript)
University of Iowa Affiliation: (*send or attach a copy of current UI transcript)
Graduate program:
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MSTP
Yes
No
Date started PhD program:
Current graduate GPA:
PhD mentor/advisor / His/her department:
Mentor/advisor
Department
Comprehensive exam taken?
Yes
No
If no, anticipated date (mo/yr):
Estimated date for completion of PhD: (mm/dd/yyyy)
***I have taken the Online CITI Training:
Yes
No
Undergraduate Degree, Training: (*attach a copy of undergrad transcript)
Undergraduate Degree, Training: (*Please attach a copy of undergrad transcript)
Institution (city, state, country):
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Degree awarded and date of award:
Degree
Date (mo/yy)
Undergraduate major(s):
Undergraduate GPA:
GRE Scores:
GRE Scores:
Verbal
Quantitative
Analytical
Analytical writing
MCAT Scores:
Phys Sci
Biology
Verbal
Writing
Advanced Subject Test (if available)
Post-Baccalaureate Education/Training:
Post-Baccalaureate Education/Training:
Institution (city, state, country):
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Area of study:
Degree awarded/Dates attended/GPA:
Degree awarded
Dates attended
GPA
Honors and/or Awards:
Honors and /or Awards:
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Publications, Abstracts or Presentations:
Publications, Abstracts or Presentations:
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Career Plans:
Career Plans:
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Letters of Recommendation:
Letters of Recommendation:
Please ask for letters of recommendation from three referees who can comment on training and
potential for conducting research in Pharmacological Sciences. These should be sent or emailed by
the referee to Linda Buckner, Department of Pharmacology, 2-471B BSB, [email protected].
List names, addresses and telephone numbers of references below:
Reference 1: (Name, Address, Telephone)
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Reference 2: (Name, Address, Telephone)
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Reference 3: (Name, Address, Telephone)
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Statement of Research Goals:
Statement of Research Goals:
This should summarize research already accomplished and plans for the future.
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Questions:
Please contact:
Linda Buckner, Department of Pharmacology
telephone: 335-7946
email: [email protected]
You may also contact an Executive Committee Member on this training grant:
Stefan Strack
Pharmacology
4-4439 [email protected]
Michael G. Anderson
Physiology
5-7839 [email protected]
Ernesto Fuentes
Biochemistry
3-4244 [email protected]
David Roman
Med Nat Prod Chem
5-6930 [email protected]
Tina Tootle
Anatomy & Cell Biology
5-7763 [email protected]
David Wiemer
Chemistry
5-1365 [email protected]
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Deadline for receipt of applications AND letters of recommendation is 4:00pm Monday, May 22, 2017.
To send this form electronically, type your name below, which will serve as your signature. Save all
files beginning with your last name followed by the source of the file (example: Smith T32 undergrad
transcript.pdf).
TO WHOM IT MAY CONCERN:
I hereby give permission to the Executive Committee screening applications for fellowship in the
Pharmacological Sciences Training Grant to examine and reproduce materials in my confidential files
for the purpose of evaluating my application.
SIGN
× HERE
clear
Checklist for application (please complete)
1. Completed application
2. Current UI transcript* (copy sent to Linda Buckner)
3. Undergraduate transcript* (copy sent to Linda Buckner)
4. Requests made for 3 letters of support
Upload Statement of Research Goals and Transcripts
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