APPLICATION
RECEIPT
DEADLINE DATE:
OCTOBER 3, 2014
APPLICATION/REGISTRATION FOR THE “Getting Started as a Successful Grant Writer & Academician” seminar at ABRCMS 2014. Registration is not transferable without proper documentation and authorization. All eligible applicants residing beyond a 50-mile radius of the San Antonio seminar location and are approved to attend the training program will receive a travel lodging assistance award (up to $250 maximum) to offset lodging expenses related to participating in the training program. Local area (within a 50-mile radius) applicants who are eligible and approved to attend the training program will receive mileage reimbursement (current IRS rates) related to the use of their personal automobiles.
DEADLINE INFORMATION: All application packets for participation in the “Getting Started as a Successful Grant Writer & Academician” seminar must be received no later than 5:00 PM EDT on FRIDAY, OCTOBER 3, 2014. Late and/or incomplete application packets will be declined upon receipt.
Applicant Eligibility Category:
[Postdoctoral Fellow, PhD Student (3rd Year minimum) or New Assistant Professor (within 1 year of completing postdoctoral training)
Name: Enter First and Last Name
Gender: Degree/Title:
Institution: Enter Institution's Name Department: Enter Department
Address: Enter Address
City: Enter City State: Enter State Code ZIP: Enter ZIP Code
E-Mail: Enter E-Mail Address TEL: Enter Contact Phone# MOBILE: Enter 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
1) Are you an individual from a background identified as being underrepresented in the biological and behavioral sciences? (required)
2) Please indicate Race/Ethnicity (required):
** If “American Indian/Native American” selected, please specify tribe and provide a copy of tribal affiliation certificate.
TRIBE: (required) SPECIFY TRIBE
** If “Other” selected, please specify - (required) SPECIFY OTHER
3) Citizenship/Residency Status: (required)
** If “USA Citizen,” provide a photocopy of one of the following: 1) Identification page of your valid USA Passport, 2) Birth Certificate,
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 NSF, NIH or other federally-funded Program at your university?(required) If “YES”, please indicate the type of federal grant: If “YES” and your funding type is not listed, enter grant info/number: ENTER GRANT INFO/NUMBER
5) Final/Terminal Degree Desired: If “Other” selected, enter other degree:
6) Are you planning to pursue a career in biomedical research?
7) Are you a FASEB Society Member?
If “Yes,” indicate Society:
If “No,” would you like to be contacted by a FASEB Society?
If “Yes,” indicate Society:
A Registration Fee of $25.00 is required to participate in the “Getting Started as a Successful Grant Writer & Academician” training seminar. No onsite registration will be available.
Credit Card Information must be provided with this form.
Payment:
Please charge my:
Account#: Enter Account Number Exp. Date: Enter Expiration Date Security Code: Enter Credit Card Security Code
Amount of authorized payment: Enter payment amount
Billing Information: (This information must be identical to the information on file at the bank which issued the credit card.)
Cardholder’s Name: Enter Name As It Appears On The Credit Card
Cardholder’s Phone Number: Enter Contact Phone#
Credit Card Billing Address (including ZIP Code): Enter Address Including ZIP Code
By selecting this checkbox, you are validating your authorization of the above transaction. Payment must be
included with this application/registration form; otherwise the application/registration will be declined upon receipt.
Faxed registrations (301.634.7353) will be accepted with credit card payment only. Faxed registrations that do not have all credit card information provided will not be processed. For questions regarding this seminar, e-mail: .
Cancellation Policy: A $15.00 administration fee will be assessed if notification is received in writing, post-marked fifteen (15) – November 21, 2015 - business days prior to the seminar. There will be no refunds for cancellations made less than fifteen (15) business days in advance of the grantsmanship training seminar. All refunds will be processed after November 28, 2014.
Americans with Disabilities: The facility hosting the grantsmanship training seminar complies with the Americans with Disabilities Act. Please contact Ms. Cordelia Adams at or 301.634.7930 no later than October 17, 2014 to inform her of your special needs/requirements. Every reasonable effort will be made to accommodate your special needs.
FASEB MARC Travel Awards (Lodging Expenses Only): All eligible applicants residing beyond a 50-mile radius of the facility (hosting the grantsmanship training seminar) who are approved to attend the training program will receive a travel award (up to $250 maximum) to offset lodging expenses. Local area (within a 50-mile radius of seminar location) applicants who are eligible and approved to attend the training program will receive mileage reimbursement (current IRS rates).
All applicants must be USA Citizens or Permanent Residents of the USA, and must reside within the USA/USA territories. The FASEB MARC Program is offering travel assistance for eligible Postdoctoral Fellows, 3rd/4th/5th Year PhD Students, and New Assistant Professors (within 1 year of completing postdoctoral training) to help support participation in the seminar program. All applicants (regardless of ethnicity) meeting the citizenship/residency requirements at USA accredited postsecondary institutions are eligible to apply for the travel awards. If eligible, you may apply for a travel award as part of this Application/Registration process. Apply early! Space is limited.
LODGING ASSISTANCE REIMBURSEMENT: Are you requesting a Travel Award to help offset your lodging expenses to allow your participation in the “Getting Started as a Successful Grant Writer & Academician” seminar at ABRCMS 2014? (required)
LOCAL RESIDENT/MILEAGE REIMBURSEMENT: Are you a San Antonio, Texas local-area resident requesting (personal automobile) mileage reimbursement to allow your participation in the “Getting Started as a Successful Grant Writer & Academician” seminar at ABRCMS 2014? (required)
EXPENSE REIMBURSEMENTS: Lodging expenses (up to $250) will be processed as reimbursements to the eligible award recipients. Original receipts will be required in order to receive reimbursement. The maximum amount to be reimbursed for travel-related lodging expenses will be $250. Mileage reimbursement for eligible local-area participants must be accompanied by a Google Maps or MapQuest printout indicating the mileage between the local resident address and the grant seminar location/facility.
The FASEB MARC Program and the 2014 Postdoctoral Preparation Institute are funded by a grant from the National Institute of General Medical Sciences, National Institutes of Health. (T36 GM-008637-19)
09/03/14
POSTDOCTORAL FELLOWS, 3rd/4th/5th Year PhD STUDENTS AND NEW ASSISTANT PROFESSORS WHO WISH TO APPLY AND REGISTER FOR THE “GETTING STARTED AS A GRANT WRITER & ACADEMICIAN” SEMINAR MUST:
1) Be a USA Citizen or a Permanent Resident of the USA, and also reside within the USA/USA territories. (A copy of one of the following - 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) Complete and submit this application form including all supporting documentation.
3) Submit a current CV/Resume (including all sources of federal funding support you receive.)
4) Submit a one-page statement demonstrating financial need and identifying potential benefits to be gained and the anticipated effect this seminar may have on your planned research career. (INCLUDE REQUESTED DOCUMENT FOR TRAVEL AWARD or MILEAGE REIMBURSEMENT ONLY.)
5) Submit a letter of recommendation on departmental letterhead signed by the mentor, department head/chair or dean. Be sure to include the email address and daytime phone number of your mentor, chair or dean.
6) Submit any required documentation (clear copy of green card, or USA Passport identification page, tribal affiliation certificate, etc.) if applicable.
7) If applicable, please list (voluntarily) any disabilities that would require the attention of the program organizers. List any device/services that would enhance your ability to participate.
All applicants must be approved by the FASEB MARC Program review committee. The FASEB MARC Program review committee will select the participants based on all supporting documentation provided by the applicants.
Applicants selected to participate in this grantsmanship training seminar will be notified by the FASEB Office of MARC and Professional Development Programs upon approval of their application/registration.
SUBMIT APPLICATION TO: ; or via USPS: FASEB MARC Program; ATTN: Grantsmanship Training at ABRCMS 2014; 9650 Rockville Pike; L-6205, Bethesda, MD 20814-3998.
REGISTRATION/TRAVEL AWARD APPLICATION CHECKLIST
Completed Registration/Travel Award Application FormCopy of current CV/Resume (including all sources of federal funding support received)
One-page Statement demonstrating financial need, identifying benefits to be gained and
anticipated effect the grantsmanship training may have on your planned research career.
(Include only if you are applying for a travel award or mileage reimbursement.)
Letter of recommendation and support from Mentor, Chair or Dean
(MUST accompany your application packet at time of submission, otherwise your
application will be declined because the packet will be an incomplete submission.)
Credit Card Payment Information for $25 Seminar Participation/Registration Fee
* 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, include a copy of Permanent Resident Card (Green Card)
* If American Indian/Native American, copy of Tribal Affiliation Certificate/Card
If applicable, provide your related ADA requirements that would require the attention
of the program organizers.
The FASEB MARC Program and the 2014 Postdoctoral Preparation Institute are funded by a grant from the National Institute of General Medical Sciences, National Institutes of Health. (T36 GM-008637-19) 09/03/14