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 (

First name:    _________________________Last name: _______________________________________


Affiliation:     _________________________________________________________________________


Address:         _________________________________________________________________________






Phone number: _________________________________________________________________________




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.

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. _________________________________________________________



If you are a trainee (pre-doctoral or post-doctoral) please provide your advisor’s name___________________________________________________________________________________________________________


and email address__________________________________________________________________________



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 ____________________.

The NIH supports this course. They request that we provide the following information. It is appreciated if you would supply us with this optional information. 

Gender:       _____  Male    ______ Female    _______ Other

Primary Appointment:  _____ Academics______ Government______ Industry


Faculty: ______Senior _____Mid-career   _____Junior

Research/Staff Scientist:  ________Senior   _______ Mid-career   ________Junior

Research Technician: ________Senior   _______ Mid-career   ________Junior

Trainee:  _______Post-doctoral   ________Pre-doctoral ___________Other (please specify______________ ________________________________________________________________)

Degrees (please check all that apply): _____ MD _____ PhD _____ MS or MA _____ BS or BA  _____Other (please specify ______________________________________________)

Ethnic Background (please check all that apply): ____ American Indian or Alaskan Native   _____Asian   _____ Black   _____ Pacific Islander   _____ White

Hispanic: ________Yes       ________No

Financially disadvantaged (as defined as ____Yes ____ No


Educationally disadvantaged background below high school level e.g. an inner-city public school: ____Yes ________No

Physically or mentally disabled:    ________Yes       ________No

If yes, please specify. Accommodations will be made to aid you in attending the course online:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________