APPLICATION
FOR ADVANCED GENE MAPPING COURSE November 7-11, 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 travel stipend, 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). _________________________________________________________
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(s) _______________
Dates: Dose 1) ________________ Dose 2)___________________ Dose 3)______________________
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: ______Professor _____Associate Professor _____Assistant Professor ______Instructor___________ Other Title (please specify ___________)
Research/Staff Scientist: ________Senior _______ Associate ________Assistant _________ Other Title (please specify______________)
Research Technician: ________Senior _______ Mid-career ________Junior ______________Other Title (please specify ______________)
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/2022-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
___________________________________________________________________________________________________