Post-Doctoral Training Program In



Post-Doctoral Training Program in Intellectual and Developmental Disabilities ResearchApplication for AdmissionDate of Application: FORMTEXT ?????CONTACT INFORMATIONName: FORMTEXT ?????Gender: FORMTEXT ?????(Last, First, Middle Initial)Current Mailing Address: Street: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip Code: FORMTEXT ?????Phone (incl. area code): FORMTEXT ????? FORMTEXT ?????E-mail address where you can be reached now and in the future (Please list a gmail, yahoo or other address you will keep permanently vs. your current institutional email): FORMTEXT ?????Permanent Home Address (if different than above)Street: FORMTEXT ????? City: FORMTEXT ????? State: FORMTEXT ????? Zip/Postal Code: FORMTEXT ?????Phone (include area or country codes): FORMTEXT ????? PERSONAL INFORMATIONDate of Birth: FORMTEXT ?????Place of Birth: FORMTEXT ?????(City, State, Country) Citizenship: NIH requires postdocs in this program to be U.S. citizens, non-citizen nationals, or permanent residents by the time of appointment. Please check one: FORMCHECKBOX U.S. Citizen FORMCHECKBOX Non-Citizen National (explanation of this status) FORMCHECKBOX Permanent ResidentEthnicity: (specify only if you are a US citizen or permanent resident) [optional] FORMCHECKBOX Hispanic/Latino Origin FORMCHECKBOX Not of Hispanic/Latino OriginRace: (specify only if you are a US citizen or permanent resident) [optional] FORMCHECKBOX American Indian or Alaska Native (A person having origins in any of the original peoples of North and south America, including Central America, who maintain tribal affiliation or community attachment)Tribal Affiliation: FORMTEXT ????? FORMCHECKBOX Black or African American (A person having origins in any of the black racial groups of Africa) FORMCHECKBOX Asian (A person having origins in any of the original peoples of the far east, southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippines, Thailand, and Vietnam) FORMCHECKBOX Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands) FORMCHECKBOX White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa) FORMCHECKBOX Biracial or Other Ethnic Specify: FORMTEXT ?????EDUCATIONList all post-secondary colleges and graduate and professional schools you have attended, including UW-Madison, beginning with most recent:InstitutionLocation (city,state, country)Field ofConcentrationDegree granted or expected (Diploma,certification)DatesAttended FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Dissertation Title: FORMTEXT ?????Current status in doctoral program (check one): FORMCHECKBOX Successfully defended dissertation – list date: FORMTEXT ????? FORMCHECKBOX Dissertation written – date defense is scheduled: FORMTEXT ????? FORMCHECKBOX Dissertation research completed - anticipated date of defense: FORMTEXT ????? FORMCHECKBOX Other (please explain) FORMTEXT ?????Members of your dissertation committee and department affiliations (specify chair):NameDepartment Affiliation1. FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ?????References (3-4): Please list the individuals you have asked to submit letters of recommendation (full name, title, and E-Mail address). One letter should come from your dissertation chair. Letters should be sent by each individual as a pdf directly to Dr. Sigan Hartley, PhD., at schafer@waisman.wisc.edu:1. FORMTEXT ?????2. FORMTEXT ?????3. FORMTEXT ?????4. FORMTEXT ?????Please indicate how you learned about this position. It is important for future recruitment of postdocs to this program. FORMTEXT ? ????To complete your application: Submit this form as part of one pdf containing all of the information listed on the website in the order indicated to Sigan Hartley, PhD at schafer@waisman.wisc.edu. INFORMATION ABOUT DISABILITY ACCOMMODATION FOR COMPLETING THIS APPLICATIONConsideration for this position requires completion of this application, as well as submitting all other materials in pdf format, as described in the job posting. Phone contact may be necessary for finalists. If you need a reasonable accommodation in order to complete the application materials or participate in a phone conversation, you may contact Eric Schafer at 608-263-2328. Note that you are not required to indicate whether or not you need an accommodation to perform the traineeship.An individual with a disability is defined by the Americans with Disabilities Act (ADA) as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. Please see the ADA website for questions and answers about job applicant accommodations: Waisman Center encourages qualified individuals with disabilities to apply. ................
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