Application Deadline: September 28, 2012 5:00 Pm Edt

APPLICATION FOR UNDERGRADUATE STUDENT OR POST-BACCALAUREATE POSTER/PLATFORM (ORAL) PRESENTERS AT THE ABRCMS CONFERENCE ONLY. You may not apply for a FASEB MARC travel award if you are receiving funding from any other sponsoring organizations. Travel Award is not transferable without proper documentation and authorization. Post-Baccalaureates must be affiliated with an established program at their institution.

You are considered to be ineligible to apply for the FASEB MARC Travel Awards to attend ABRCMS if you receive financial support from ANY program funded by the National Science Foundation (NSF) or from ANY program of the Minority Opportunities in Research (MORE) Division of the National Institute of General Medical Sciences, National Institutes of Health (NIGMS/NIH.) NIGMS MORE Division Programs include: MBRS, SCORE, RISE, BRIDGES, MARC U*STAR, PREP, etc.

You are considered to be ineligible to apply for the FASEB MARC Travel Awards to attend ABRCMS if you have attended ABRCMS in prior years (2008-2011.)

APPLICATION DEADLINE: SEPTEMBER 28, 2012 – 5:00 PM EDT

This application is being submitted for travel award support for the following scientific meeting:

> Select either ABRCMS only or ABRCMS + PreCon PrepABRCMS only - Nov. 7 -10, 2012ABRCMS + PreCon Prep Workshop - Nov. 6 -10, 2012

POSTER/PLATFORM (ORAL) PRESENTATION TRAVEL AWARD APPLICANT (must be FIRST AUTHOR and presenting at the meeting.)

Applicant Eligibility Category: Select Applicant StatusUNDERGRADUATE FRESHMANUNDERGRADUATE SOPHOMOREUNDERGRADUATE JUNIORUNDERGRADUATE SENIORPOST-BACCALAUREATE (Affiliated w/Postbac Program) (Undergraduate Student or Post-Baccalaureate ONLY)

Name: Enter First and Last Name

Gender: Select GenderFEMALEMALE Degree/Title: Select Degree/TitleDr.Mr.Ms.Mrs.MD/PhDPhD

Institution: Enter Institution's Name Department: Enter Department

Address: Enter Address

City: Enter City State: Enter State Code ZIP: Enter ZIP Code

EMail: Enter E-mail Address TEL: Enter Contact Phone# MOBILE: Enter Mobile Phone#

This information is required for follow-up program evaluation data and must be provided by applicant. (Required)

Home Address: Enter Address

City: Enter City State: Enter State Code ZIP: Enter ZIP Code

Email: Enter E-Mail Address TEL: Enter Contact Phone# MOBILE: Enter Mobile Phone#

1.  Are you a member of an ethnic minority group identified as being underrepresented in the biological and behavioral sciences? Select YES or NOYESNO

2.  Please indicate Race/Ethnicity (required): Select URM Race/EthnicityAlaskan NativeAmerican Indian/Native AmericanBlack/African AmericanChicanoHispanicLatinoPacific Islander (Hawai'i)Pacific Islander (Guam)Other

** If “American Indian/Native American,” please specify tribe and provide a copy of tribal affiliation certificate.

TRIBE: SPECIFY TRIBE

** If “Other,” please specify - SPECIFY OTHER

3.  Citizenship/Residency Status: Indicate Citizenship/Residency StatusUSA CITIZENPERMANENT RESIDENT OF USA

** If “Permanent Resident of USA,” provide a copy of your “Green Card” with this application.

4.  Are you funded by an NSF, NIGMS or other NIH-sponsored Program at your university? Indicate YES or NONOYES

5.  Final Career/Long-term Degree Desired: Indicate DegreeBA/BSMSMDDVMPharmDPhDOTHER COMBINED PROFESSIONAL DEGREE/PhD If “Other” selected, enter other degree:

6.  Are you planning to pursue a career in biomedical research? Indicate Your SelectionYESNOUNSURE

7.  Have you ever worked in a research laboratory as a summer intern or in a paid position? Indicate YES or NOYESNO If “Yes,” how many times? Indicate Your Selection123 OR MOREN/A

8.  Are you interested in meeting exhibitors offering summer research opportunities for undergraduate students during the ABRCMS 2012 meeting? Indicate YES or NOYESNO

9.  Are you a FASEB Society Member? Indicate YES or NOYESNO

If “Yes, “indicate Society: Indicate SocietyAAAAAIABRFACSMAFMRAPSAPepSASBMBASCIASHGASIPASNASBMRASPET(See next list for additional societies) Indicate SocietyBMESEMSENDOGSAHSCISCBProteinSDBSFGSPRSSRTeratology

If “No,” would you like to be contacted by a FASEB Society regarding membership? Indicate YES or NOYESNO

If “Yes,” indicate Society: Indicate SocietyAAAAAIABRFACSMAFMRAPSAPepSASBMBASCIASHGASIPASNASBMRASPET(See next list for additional societies) Indicate SocietyBMESEMSENDOGSAHSCISCBProteinSDBSFGSPRSSRTeratology

10.  There will be 15 FASEB Member Societies participating as exhibitors on “FASEB Row” at the ABRCMS 2012. Please indicate THREE (3) FASEB Societies booths you are interested in visiting during the ABRCMS 2012 meeting? a) Indicate SocietyAAAABRFACSMAPSASBMBASIPASNASPETBMESENDOGSAHSCISCBSDBSSRNone of the above b) Indicate SocietyAAAABRFACSMAPSASBMBASIPASNASPETBMESENDOGSAHSCISCBSDBSSRNone of the above c) Indicate SocietyAAAABRFACSMAPSASBMBASIPASNASPETBMESENDOGSAHSCISCBSDBSSRNone of the above

11.  Are you interested in obtaining information on the GRE or MCAT? Select GRE or MCATGREMCATNone of the above

POSTER/ORAL PRE-CONFERENCE PREPARATION WORKSHOP: FASEB MARC will hold a Poster/Oral Pre-conference Preparation Workshop on Tuesday, November 6, 2012 to provide our poster/oral presentation travel awardees with an opportunity to practice their presentations and obtain feedback from the designated Pre-Conference Workshop Mentors/Coaches. If you would like to participate in this workshop, you must indicate your plans to participate at the time you submit this application form. To accommodate the extra hotel night and per diem (arrival on November 5, 2012), the FASEB MARC travel award amount will be increased to cover related expenses up to $2,150. If you do not plan to attend the Pre-Conference Workshop, the FASEB MARC travel award amount will be for related expenses up to $1,850.

I plan to participate in the FASEB MARC Poster/Oral Pre-conference Workshop at the ABRCMS. Indicate YES or NOYESNO

ABOUT THE FASEB MARC TRAVEL AWARDS: FASEB is offering a limited number of travel awards of up to $1,850 ($2,150 for Poster/Oral Pre-Conference Preparation Workshop participants) for each undergraduate student or post-baccalaureate to help defray meeting registration and travel-related expenses associated with meeting/conference attendance. These funds are meant to defray meeting registration, air, ground, lodging/subsistence expenses only. NOTE: Travel awards are processed as reimbursements after the meetings. Receipts will be required in order to receive reimbursement. The maximum amount to be reimbursed for meeting registration/travel-related expenses to be reimbursed is $1,850 ($2,150 for Poster/Oral Pre-Conference Preparation Workshop participants).

UNDERGRADUATE STUDENTS AND POST-BACCALAUREATES WHO WISH TO BE CONSIDERED FOR TRAVEL AWARD FUNDING MUST:

1)  Be a USA Citizen or a Permanent Resident of the USA. (Copy of Permanent Resident “green card’ will be required.)

2)  Advance register for the meeting. Follow abstract submission guidelines.

3)  Submit your abstract and appropriate materials by the deadline date for the meeting you are applying for. NOTE: When applying to attend the ABRCMS meeting, please submit your travel award application to FASEB MARC Program at the same time you submit your abstract to ABRCMS. When you receive your notification of acceptance letter for your research abstract informing you that your presentation will be included as part of the ABRCMS 2012 Program, you may complete the application process by submitting the acceptance letter at a later date.

4)  Complete and submit this application form including:

a.  A copy of your submitted/accepted abstract. You must be the FIRST AUTHOR on the abstract.

b.  A letter on departmental letterhead signed by your mentor, chair or dean that affirms your post-baccalaureate or student status, and request consideration for a FASEB MARC Poster/Platform (Oral) Presenter Travel Award. Be sure to include the email address and daytime phone number of your mentor, chair or dean.

c.  A current copy of your CV/resume. Include all sources of fellowship/scholarship funding you receive.

5)  Post-Baccalaureates applying for FASEB MARC Travel Awards must be affiliated with an established Post-Baccalaureate program at their home institution.

Abstracts submitted and accepted as poster or platform (oral) presentations will be used as the basis for the awards. The FASEB MARC Program review committee will select the award recipients based on the accepted scientific abstracts of applicants who are eligible for MARC funding as specified by the National Institute of General Medical Sciences, National Institutes of Health (NIGMS/NIH.)

Applicants selected to receive a travel award will be notified by the FASEB MARC Program upon approval of their application.

SUBMIT APPLICATION TO: FASEB MARC Program, 9650 Rockville Pike, Bethesda, Maryland 20814-3998; Tel: 301.634.7021; FAX: 301.634.7353; eMAIL: ; Internet: http://www.faseb.org/marc

The FASEB MARC Program is funded by a generous grant from the National Institute of General Medical Sciences, National Institutes of Health. T36 GM008059-30

FASEB MARC TRAVEL AWARD APPLICATION CHECKLIST

Completed Travel Award Application Form
Copy of Notification of Abstract Acceptance for Meeting Program (submit at later date)
Copy of Submitted/Accepted/Programmed Abstract
Letter of recommendation from Mentor, Chair or Dean
Copy of CV/Resume (including all sources of fellowship/scholarship funding)
* If Permanent Resident, copy of ‘Green Card’
* If American Indian/Native American, copy of Tribal Affiliation Certificate/Card