APPLICATION FOR ADVANCED GENE MAPPING COURSE 2022 – 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 advancedgenemapping@gmail.com.

First name:    _________________________Last name: _______________________________________

 

Affiliation:     _________________________________________________________________________

 

Address:         _________________________________________________________________________

 

_________________________________________________________________________

 

_________________________________________________________________________

 

Phone number: _________________________________________________________________________

 

E-mail:_______________________________________________________________________________


Applying for fellowship
:    __________Yes   __________No

 

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. _________________________________________________________

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

and email address________________________________________________________________________

Room Sharing: 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.

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 ______________________________________________________

Have you received a COVID vaccine ______YES _______No

Type of vaccine _______________

Dates:  Dose 1) ________________   Dose 2)___________________

Please submit a scan of your COVID vaccination card with your application.

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

Status:

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 by https://aspe.hhs.gov/2021-poverty-guidelines): ____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:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________