APPLICATION FOR ADVANCED GENE MAPPING COURSE 2019– New York

Please fill out this form to apply to the Advance Gene Mapping Course. Paste the filled-out form into the body of an e-mail. Please e-mail the additional material which is requested (see below) as an e-mail attachment. Submit the application to Katherine Montague (advancedgenemapping@gmail.com).

First name: _________________________Last name: _______________________________________

Affiliation: _________________________________________________________________________

Address: _________________________________________________________________________

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Work number: _________________________________________________________________________

E-mail:_______________________________________________________________________________

Applying for fellowship: __________Yes __________ No

Are you interested in sharing a room with another course participant? _________ Yes___________ No

We will supply you with a list of names and email addresses from other course participants who are also interested in sharing a hotel room.

Please attach a copy of your curriculum vitae and a letter describing your experience with genetic epidemiology, association studies, gene mapping of complex or Mendelian traits and/or statistical genetics. If you are analyzing data for specific studies or developing methods please explain in your letter. If you are applying for a fellowship please also submit a letter of recommendation from your advisor or department head.

Please tell us about your research interest (e.g. Cardiovascular diseases, Bipolar, Schizophrenia, Method development in statistical genetics). This information will be included in the course list which will be distributed to all course participants.

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The NIH supports this course. They request that we provide the following information. It is appreciated if you would supply us with this information. If you wish to share a room please be sure to include information on your gender.

Gender: _____ Male ______ Female

Primary Appointment:_____ Academics______ Government______ Industry

Status:

Faculty ______Senior;_____Mid-career; _____Junior

Research/Staff Scientist ________Senior; _______ Mid-career; ________Junior

Research Technician ________Senior; _______ Mid-career; ________Junior

Trainee ______Post-doctoral ________Pre-doctoral ________Master _______Bachelor

Degrees:_____ MD_____ PhD_____ MS or MA_____ BS or BA _____Other (please specify _____________________________)

Ethnic Background: ____ American Indian or Alaskan Native _____ Asian or Pacific Islander

____ Black, not of Hispanic origin ____ Hispanic

____ White, not of Hispanic origin

Are you a USA Citizen _____Yes ________No

If No are you a

Permanent Resident (Green Card holder) ______yes _______No

Other type of visa _________yes ________no

If Yes type of visa ____________________.