Application for Pre-doctoral Fellowship Support

Mechanisms and Clinical Presentation of Pain

This training program will: 1] enroll pre-doctoral trainees after two years in graduate school and 2] renew training support for an additional year, based on an evaluation of progress (see last page).

Applicant Information:

Name: / Sex
M / F
Prior NRSA/T32 support? No 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
What is your racial background? Check one or more:
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Asian
Black or African American
White
Do Not Wish to Provide / Do you have a disability?
Yes No 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

University of Pittsburgh(or other) Affiliation:

College: ______Department:______

Date Joined: Ph.D. Comps Taken? ______

Expected Date for Completion of Ph.D.

Ph.D. Mentor (Advisor):_____

GPA______please attach a current copy (not official) of yourPitt graduate transcript

Bachelor's Degree:

Institution and Year:

Undergraduate GPA ______

Graduate Record Exam Scores:

Verbal ______Quantitative______Writing ______

Post-Baccalaureate Education/Training:

Institution ______

Dates ______

Nature of Experience

Additional Degrees Earned GPA

Responsible Conduct of Research Taken?

(Course title, number and date)

Honors and/or Awards(list as appropriate):

Publications or Presentations(list as appropriate):

Career Plans:

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

Please attach a brief description of a project you would like to pursue during the training period. A NIH styleSpecific Aims page would be the ideal format for such a description where you provide the rationale for a central hypothesis you would like to test and then briefly describe how you would like to test your hypothesis.

New Applicants

Please ask for letters of recommendation from three referees who can comment on your training and potential for conducting research in Mechanisms and Clinical Presentation of Pain. These should be sent directly to Michael Gold, () Center for Pain Research, W1451 BST. List names, addresses and telephone numbers of references below:

NameAddressTelephone

1.

2.

3.

TO WHOM IT MAY CONCERN:

I hereby give permission to the University of Pittsburgh committee screening applications for fellowship support from the Mechanisms and Clinical Presentation of Pain NIH Training Grant to examine and reproduce materials requested above for the purpose of evaluating my application.

Name Date

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. List publications, abstracts, etc. (please limit to two pages).

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