SRCLD - Online Student Travel Award Application

SRCLD Student Travel Award Online Application

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First Name:
Last Name:
Affiliation:
Department:

Mailing Address

Include affiliation and department in mailing address? Yes No
Street:
City:		State:
Zip:		Country:

Contact Information

Phone:
Email:

Race/Ethnicity

The NIH requires that we collect this information. Please specify the racial and ethnic category that best describes you:

Other Information

Name of advisor confirming student status and affiliation:
Current degree program:
Optional: Are you a member of an under-represented minority group, according to the NIH definition?*	Yes No
Are you submitting a poster?	Yes No
If yes, are you the first author?	Yes No

Citizenship status:

U.S. citizen
Non-U.S. citizen Country (if not U.S.):

*Nationally, underrepresented groups in biomedical research careers include but are not limited to African Americans, Hispanic Americans, American Indians/Alaska Natives, Native Hawaiians and Pacific Islanders.