Application for Pharmacological Sciences



Application for Post-doctoral Fellowship Support

Mechanisms and Clinical Presentation of Pain

Applicant Information:

|Name: | |

| |Sex |

| |M |F | |

| | | | |

| | |

|Prior NRSA/T32 support? No [pic] Yes (identify below): |Permanent Mailing Address: |

| | |

|Citizenship: | |

|U.S. Citizen or Noncitizen National | |

|Non-U.S. Citizen: | |

|With a Permanent U.S. Resident Visa (“Green Card”) | |

|With a Temporary U.S. Visa | |

|If not a U.S. citizen, of which country are you a citizen? | |

| |

|Are you Hispanic (or Latino)? Yes No Do Not wish to Provide |

| |Do you have a disability? |

|What is your racial background? Check one or more: |Yes No Do Not Wish to Provide |

|American Indian or Alaska Native | |

|Native Hawaiian or other Pacific Islander | |

|Asian | |

|Black or African American | |

|White | |

|Do Not Wish to Provide | |

| |If yes, which of the following categories describes your Disability (ies): |

| | Hearing | Mobility/Orthopedic Impairment |

| | Visual | Other |

| |Are you from a disadvantaged background? |

| | Yes No Do Not Wish to Provide |

Responsible Conduct of Research Taken?

  (Course title, number and date)

Attach:

• curriculum vitae describing Post-Baccalaureate Education/Training, Honors and/or Awards and Publications

• description of past research accomplishments

• NIH style Specific Aims page, providing the rationale for a central hypothesis you would like to test, Aims and research approach(es) to test your hypothesis

• name(s) of Pain Center Member(s) you would like to work with and reason(s) for your choice(s)

• statement of career goals

• names and contact information of three referees who will send letters in support of your application directly to Michael Gold (msg22@pitt.edu), Center for Pain Research.

Current Trainees

Trainees seeking to renew fellowships must prepare a brief (no more than four, double-spaced pages) summary of progress and request a letter of recommendation from your research advisor. It is not necessary to complete any of the preceding pages.

Statement of Research Goals for the period for which continued funding is requested. This should briefly summarize research already accomplished and plans for the future. This document should also include justification for a second year of support. List publications, abstracts, etc. (please limit to two pages).

------------------------------------------------------------------------------------------------------------

-----------------------

[pic]

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download