APPLICATION
FOR ADVANCED GENE MAPPING COURSE 2022 – New York
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:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________