APPLICATION for FACULTY/MENTOR and TWO (2) STUDENTS ONLY. You May Not Apply for a FASEB

APPLICATION FOR FACULTY/MENTOR AND TWO (2) STUDENTS ONLY. You may not apply for a FASEB MARC travel award if you are receiving funding from any of the sponsoring Societies. Travel Award is not transferable without proper documentation and authorization. All applicants must NOT be presenting a poster/platform presentation or at any time be staffing an exhibit booth at the meeting. Violation of this policy during the meeting will invalidate your travel award.

DEADLINE INFORMATION for submittal of FASEB MARC Applications is listed on the FASEB Eligible National Scientific Meetings page on the FASEB MARC Program web site –

Please indicate the scientific meeting that you are requesting travel support for (select only one):

JANUARY – DECEMBER 2013 > PLEASE SELECT ISCB MEETINGCSHALS 2013: Feb 27-Mar 1, 2013GLBIO 2013: May 14-16, 2013Rocky 2013: Dec 12-14, 2013

NOTE: Faculty/Student Travel Awards are not available for International Meetings or meetings held in Alaska and Hawai’i.

FACULTY/MENTOR: Are you requesting funding for yourself? Indicate YES or NOYES, I am requesting funding.NO, I am not requesting funding.

Applicant Eligibility Category: Select Applicant StatusFACULTY/MENTOR

Name: Enter First and Last Name

Gender: Select GenderFEMALEMALEDegree/Title: Select TitleDr.Mr.Mrs.Ms.

Home Institution: Enter Institution's Name Department: Enter Department

Home Institution Address: Enter Address

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

Email: Enter E-mail AddressTEL: Enter Contact Phone# MOBILE: Enter Mobile#

1) Are you an individual from a background identified as being underrepresented in the biological and behavioral sciences? Select YES or NOYESNO

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

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

TRIBE: SPECIFY TRIBE ** If “Other” race/ethnicity selected, please specify - SPECIFY OTHER

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

** If “USA Citizen,” provide a photocopy of one of the following: 1) Identification page of your valid USA Passport, 2) Birth Certificate,

3) Certificate of Naturalization, 4) Certificate of United States Citizenship, or 5) Consular Registration of Birth Abroad Form with

this application.

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

NOTE: The above documents are requested for verification purposes only. After citizenship or permanent residency status has been

confirmed by FASEB MARC Program staff, the documents are destroyed through a secure shredding process.

4) Are you funded by an NIH, NSF or other federally-funded program at your university?Indicate YES or NONOYES

5) Have you previously received a FASEB MARC Faculty/Mentor and Students Travel Award? Indicate YES or NONOYES

6) Are you a FASEB Society Member? Indicate YES or NOYESNO

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

If “No,” would you like to be contacted by a FASEB Society regarding membership? Indicate YES or NOYESNO
If “Yes,” indicate Society: Indicate SocietyAAAAAIABRFACSMAFMRAMPAPSAPepSASBMBASCIASHGASIPASNASBMRASPET(See next list for additional societies)Indicate SocietyBMESEMGSENDOGSAHSCISCBProteinSDBSFGSPRSSRTS

STUDENT/MENTEE #1: MUST NOT BE PRESENTING A POSTER/PLATFORM PRESENTATION OR STAFFING EXHIBIT BOOTH AT THE MEETING.

Applicant Eligibility Category: Select Applicant StatusUNDERGRADUATE STUDENTGRADUATE STUDENTPhD STUDENT

Name: Enter First and Last Name

Gender: Select GenderFEMALEMALEDegree/Title: Select TitleMr.Mrs.Ms.

Home Institution: Enter Institution's Name Department: Enter Department

Home Institution Address: Enter Address

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

Email: Enter E-mail AddressTEL: Enter Contact Phone# MOBILE: Enber Mobile#

______

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 AddressTEL: Enter Contact Phone# MOBILE: Enter Mobile#

______

1) Are you an individual from a background identified as being underrepresented in the biological and behavioral sciences? Select YES or NOYESNO

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

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

TRIBE: SPECIFY TRIBE ** If “Other” race/ethnicity selected, please specify - SPECIFY OTHER

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

** If “USA Citizen,” provide a photocopy of one of the following: 1) Identification page of your valid USA Passport, 2) Birth Certificate,

3) Certificate of Naturalization, 4) Certificate of United States Citizenship, or 5) Consular Registration of Birth Abroad Form with

this application.

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

NOTE: The above documents are requested for verification purposes only. After citizenship or permanent residency status has been

confirmed by FASEB MARC Program staff, the documents are destroyed through a secure shredding process.

4) Are you funded by an NIH, NSF or other federally-funded program at your university? Indicate YES or NONOYES

5) Final Career/Long-term Degree Desired: Indicate DegreeBA/BSMSMDPhDOTHER 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 a FASEB Society Member? Indicate YES or NOYESNO

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

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

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

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

STUDENT/MENTEE #2: MUST NOT BE PRESENTING A POSTER/PLATFORM PRESENTATION OR STAFFING EXHIBIT BOOTH AT THE MEETING.

Applicant Eligibility Category: Select Applicant StatusUNDERGRADUATE STUDENTGRADUATE STUDENTPhD STUDENT

Name: Enter First and Last Name

Gender: Select GenderFEMALEMALEDegree/Title: Select TitleMr.Mrs.Ms.

Home Institution: Enter Institution's Name Department: Enter Department

Home Institution Address: Enter Address

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

Email: Enter E-mail AddressTEL: Enter Contact Phone# MOBILE: Enter Mobile#

______

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

Permanent Home Address: Enter Address

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

Email: Enter E-Mail AddressTEL: Enter Contact Phone# MOBILE: Enter Mobile#

______1) Are you an individual from a background identified as being underrepresented in the biological and behavioral sciences? Select YES or NOYESNO

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

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

TRIBE: SPECIFY TRIBE ** If “Other” race/ethnicity selected, please specify - SPECIFY OTHER

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

** If “USA Citizen,” provide a photocopy of one of the following: 1) Identification page of your valid USA Passport, 2) Birth Certificate,

3) Certificate of Naturalization, 4) Certificate of United States Citizenship, or 5) Consular Registration of Birth Abroad Form with

this application.

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

NOTE: The above documents are requested for verification purposes only. After citizenship or permanent residency status has been

confirmed by FASEB MARC Program staff, the documents are destroyed through a secure shredding process.

4) Are you funded by an NIH, NSF or other federally-funded program at your university? Indicate YES or NONOYES

5) Final Career/Long-term Degree Desired: Indicate DegreeBA/BSMSMDPhDOTHER 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 a FASEB Society Member? Indicate YES or NOYESNO

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

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

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

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

ABOUT THE FASEB MARC TRAVEL AWARDS: FASEB is offering a limited number of travel awards (up to $1,850) for each applicant 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. Original receipts will be required in order to receive reimbursement. The maximum amount to be reimbursed for meeting registration/travel-related expenses is $1,850.

THIS APPLICATION PACKET MUST BE COMPLETED BY AND SUBMITTED BY THE FACULTY/MENTOR. APPLICATION PACKETS SUBMITTED BY STUDENTS/MENTEES WILL BE DECLINED UPON RECEIPT.

FACULTY/MENTORS AND STUDENTS WHO WISH TO BE CONSIDERED FOR TRAVEL AWARD FUNDING MUST:

1) Be a USA Citizen or a Permanent Resident of the USA. (Copy of USA Passport ID Page, Birth Certificate, Certificate of Naturalization, Certificate of United States Citizenship, Consular Registration of Birth Abroad, or Permanent Resident “green card’ will be required.)

2) FACULTY MENTOR: Submit a CV/Resume and a letter describing the anticipated benefits to be derived from attendance at one of the eligible meetings. The discussion should identify the specific benefits that you expect for yourself, your students, your institution and its education program in the biomedical sciences. Please include all sources of funding received by mentor/mentees.

3) Each STUDENT must submit a CV/Resume and write a one-page statement identifying potential benefits to their planned research career. CV/Resume must include all sources of funding received.

4) Submit a letter or recommendation on departmental letterhead signed by the department head/chair or dean. Be sure to include the email address and daytime phone number of your mentor, chair or dean. Any required documentation (copy of green card, tribal affiliation certificate, etc.)

The FASEB MARC Program review committee will select the award recipients based on the faculty/mentor’s and students’ written statements of benefits to be gained by attending the meeting, and all supporting documentation from applicants who are eligible for MARC funding as specified by the National Institute of General Medical Sciences, National Institutes of Health (NIGMS/NIH.) Faculty/Mentors and students who demonstrate an active and apparent mentoring relationship will be given preference. 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:

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

TRAVEL AWARD APPLICATION CHECKLIST

Completed Travel Award Application Form
Copy of Faculty/Mentor CV/Resume (including all sources of funding you are receiving/have received.)
Copy of Students CV/Resume (including all sources of fellowship/scholarship funding)
Letter of recommendation and support from Department Head/Chair or Dean
(Do not submit separately. This document MUST accompany your application packet at
time of submission, otherwise your application packet will be declined upon receipt.)
Copy of Faculty/Mentor “Benefits to be gained” statement
Copy of Students “Benefits to be gained” statement
** If USA Citizen, copy of USA Passport ID Page, Birth Certificate, Certificate of Naturalization,
Certificate of United States Citizenship, or Consular Registration of Birth Abroad
** If Permanent Resident, copy of ‘Green Card’
** If American Indian/Native American, copy of Tribal Affiliation Certificate

PLEASE BE ADVISED: WE DO NOT ACCEPT PIECEMEAL SUBMISSIONS. ALL

INCOMPLETE OR LATE APPLICATION PACKETS WILL BE DECLINED UPON RECEIPT.