*Indicates Required Response

The FASEB DREAM Trainee Travel Awardis available for trainees only. The award is not transferable without proper documentation and authorization. You may not apply for a FASEB DREAM award if you are receiving funding from any other source or sponsoring organization.

DEADLINE INFORMATION: All complete application packets forthis award must be received no later thanDecember 8, 2017 (5PM EST). Late and/or incomplete application packets will be declined upon receipt.

*indicates required response

* Applicant Eligibility Category: Select Applicant StatusAdvanced Graduate/PhD StudentPostdoctoral FellowEarly-Career Professional

* Name: Enter First and Last Name

* Gender: Select Gender IdentityFemaleMale* 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 ZIPCode

* Email: Enter E-mail Address* TEL: Enter Contact Phone# FAX: Enter Mobile#

Therequested information is required for follow-up program evaluation data and must be provided by applicant.
* Home Address: Enter Home Address

* City: Enter City * State: Enter State Code * ZIP: Enter ZIPCode

* Do you give FASEB permission to send future emails about: Please select one...FASEB onlyFASEB MARC/Diversity Programs onlyI don't want to receive any emails.
* Are you 18 years or older and give permission to FASEB or a FASEB-approved evaluation consultant to contact you about future studies involving FASEB DREAM award recipients? Select YES or NOYESNO

ABOUT THE FASEB DREAMTRAINEE TRAVELAWARDS: APPLY EARLY!! FASEB is offering a limited number of travel awards of up to $1,300 for underrepresented advanced graduate students, postdoctoral fellows and early career professionals to help defray course registration and travel-related expenses associated with the 2018 APS Professional Skills Training Course. These funds are meant to defray the expenses associated with participating in the course: $825 towards registration, airfare and meals that are not provided. The maximum amount to be reimbursed for course registration/travel-related expenses is $1,300.

Full-time advanced graduate/PhD students, postdoctoral fellowsand early-career professionals (who are identified as being from a group considered underrepresented in the biomedical and behavioral sciences) are eligible to apply for the trainee awards. Full-time advanced graduate/PhDstudents, postdoctoral fellows and early-career professionals at accredited minority institutions are also eligible to apply for the traineeawards. These are federally-funded awards and are restricted to USA Citizens/Legal Permanent Residents of the USA. The amount of the award is up to $1,300 maximum for the APS 2018 PSTCparticipation and must be applied to related expenses including travel (air and ground transportation) and course registration.

The awards will be processed as reimbursements to the award recipientsafter the course is over. Original receipts will be required in order to receive reimbursement. The maximum amount to be reimbursed for the course and/or travel-related expenses will be indicated in the award recipient’s award letter.

ADVANCED GRADUATE/PHD STUDENTS, POSTDOCTORAL FELLOWS AND EARLY CAREER PROFESSIONALS WHO WISH TO BE CONSIDERED FOR TRAVEL AWARD FUNDING MUST:

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

2)Meet the eligibility requirements found here:

3)Complete and submit this application form including:

1. Graduate/PhD Students/Postdocs Only: A letter on departmental letterhead signed by your mentor, chair or dean that affirms your postdoctoral or student status. Be sure to include the email address and daytime phone number of your mentor, chair or dean.
2. A current copy of your CV/resume including all sources of funding.
3. A one-page statement detailing the benefit you will receive by participating in the course.

PLEASE COMPLETE ALL QUESTIONS LISTED BELOW *indicates required response

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

2)*Please indicate Underrepresented Group Select Underrepresented GroupDisability: Mental ImpairmentDisability: Physical ImpairmentEthnic: Alaskan NativeEthnic: American Indian/Native AmericanEthnic: Black/African AmericanEthnic: ChicanoEthnic: HispanicEthnic: LatinoEthnic: Pacific Islander (Hawai'i)Ethnic: Pacific Islander (Guam)Other (if Group/Ethnicity not listed)

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

** If “Other” selected, please specify -Specify Other Ethnicity Or Underrepresented Group

3)* Citizenship/Residency Status: Indicate Citizenship/Residency StatusUSA CITIZENLEGAL PERMANENT 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,

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

application.

** If “Legal 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 Diversity Resources Program staff, the documents are destroyed through a secure shredding process.

4)*Have you ever attended a similar or related short course? Indicate YES or NOYESNO

If “Yes,” how many times? Indicate Your Selection123 OR MOREN/A

5)*Are you funded by an NSF, NIH or other federally-funded Program at your university?Indicate YES or NONOYES
If “YES”, please indicate the type of federal grant: Indicate Federal Grant TypeF30: NRSA Predoctoral MD/PhD FellowshipF31: NRSA Predoctoral FellowshipF32: NRSA Postdoctoral FellowshipF33: NRSA Individual Senior FellowshipsT32: NRSA Institutional Research Training GrantT35: NRSA Short-Term Insitutional Res TrainingT34: NRSA MARC U-STAR (Undergraduate)K01: Mentored Research Scientist Development AwardK02: Independent Scientist AwardK05: Established Investigator Award in Cancer PrevK07: Academic Creer AwardK08: NIH Mentored Clinical Scientist Career DevK12: Mentored Clinical Scientist Development ProgK22: Transition Career Development AwardK25: Mentored Quantitative Research Career DevelK23: Mentored Clinical Career Development AwardsK99/R00: Pathway to Independence AwardR25: Initiative for Maximizing Student DevelopmentR25: Postbaccalaureate Research Education ProgramR25: Research Initiative for Sci Enhancement**Not Listed**
If “YES” and your funding type is not listed, enter grant info/number: Enter Grant Info/Number

6)*Final Career/Long-term Terminal Degree Desired or Earned: Indicate DegreeBA/BSMSMDPhDOTHER COMBINED PROFESSIONAL DEGREE/PhD
If “Other” selected, enter other degree:Specify Other

7)*Are you a current FASEB Society Member? Indicate YES or NOYESNO
*If “Yes,” indicate Society: Indicate SocietyAAAAAIABRFACSMAFMRAGEAMPAPSAPepSASBMBASCIASHGASIPASNASBMRASPET(See next list for additional societies)Indicate SocietyBMESESGSAHCSISCBPSSDBSEBMSFGSFRBMSPRSSRTSUSHUPO

Americans with Disabilities Act - For Applicants Who Self-identified as “Disability: Mental” or “Disability: Physical” as an Underrepresented Group in #3 above: An individual with a physical or mental impairment that substantially limits one or more major life activities is eligible to apply for this award. Please list any disabilities that would require reasonable accommodation and the attention of the program organizers. List any devices/services that would enhance your ability to participate in the training course. Please explain in detail.

All award applicants must be approved by the FASEB Diversity Resources Program review committee. The FASEB Diversity Resources Program review committee will select the award recipients based on all supporting documentation from applicants who are eligible for funding as specified by the National Institute of General Medical Sciences, National Institutes of Health (NIGMS/NIH.) In addition, preference will be given to FASEB Society members. Funding for the awards is contingent upon funding availability. Apply early! Applications will be reviewed and approved on a rolling basis.

An applicant selected to receive an award will be notified by the FASEB Diversity Resources Program staff upon approval of the applicationand verification that the applicanthas been accepted into the 2018Writing for Scientific Journals Course.

SUBMIT APPLICATION TO: FASEB Diversity ResourcesProgram Manager at , or via USPS: FASEB Diversity Resources Program; ATTN: APS 2018 PSTCTA; 9650 Rockville Pike; Room E-117, Bethesda, MD 20814-3998.

The FASEB Diversity Resources Program is funded by grants from the National Institute of General Medical Sciences, National Institutes of Health. R25GM116706 and T36GM008637

FASEB DREAMTRAINEE TRAVELAWARD APPLICATION CHECKLIST (APS 2018 PSTC)

Completed Travel Award Application Form
Graduate/PhD Students/Postdocs Only: Letter of recommendation 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 considered to be an incomplete submission.)
Copy of CV/Resume including all sources of funding you are receiving/have received.
One-page statement detailing the benefit you will receive by participating in the course.
** 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 Legal Permanent Resident, copy of ‘Green Card’
** If American Indian/Native American, copy of Tribal Affiliation Certificate/Card
If applicable, include disability statement and ADA-related reasonable accommodation request.

PLEASE BE ADVISED: WE DO NOT ACCEPT PIECEMEAL SUBMISSIONS. ALL INCOMPLETE OR LATE APPLICATION PACKETS WILL BE DECLINED UPON RECEIPT.