NHLBI Progenitor Cell Biology Consortium (PCBC)
Human Induced Pluripotent Stem Cells and Their Differentiation
into Endoderm and Lung-Progeny Course
The Center for Regenerative Medicine (CReM)
Boston University Medical Center
Boston, MA
April 9, 2018 – April 13, 2018
Application Form
Name: ___________________________ ______ ___________________________________
First Middle Initial Last
Yes No
Degrees: Ph.D. ( ) ( )
M.D. ( ) ( )
Other ( ) ( )
Address: _________________________________________________________________________
Street 1
_________________________________________________________________________
Street 2
_________________________________________________________________________
City State Zip Code
Telephone Number (Voice): ______________________________________________
FAX Number: _________________________________________________________
Email Address: ________________________________________________________
PCTC Research Hub: ____________________________________________________________________ubHHHNfkdfdj
Research Hub (U01) Principal Investigator: ___________________________________________________
U.S. Residency Status: ( Citizen; ( Permanent Resident or Applicant; ( Student VISA; ( Work VISA; ( Teacher/Researcher VISA; ( Other.
Yes No
Will Lodge at the Hampton Inn and Suite, Boston Crosstown Center: ( ) ( )
PCTC Research Project Title: _____________________________________________________________
Basic Cell Culture Technical Experience: Yes No
( ) ( )
Describe: ______________________________________________________________________________
______________________________________________________________________________________
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