DEMOGRAPHICS

Name ______

Last name (or family name) First name Middle initial

Permanent address: ______

Address 1 Home phone: (XXX) XXX-XXXX

______

Address 2 Alternate phone: (XXX) XXX-XXXX

______

City Email

______

State or Province Zip or Postal code Country

Current mailing address and contact information (if different than above)

Is the current mailing address the same as the permanent address? Yes No

______

Address 1 Home phone: (XXX) XXX-XXXX

______

Address 2 Alternate phone: (XXX) XXX-XXXX

______

City Email

______

State or Province Zip or Postal code

Effective until what date? ______/ ______

month year

Last 4 digits of Social Security #: X X X – X X – _ _ _ _

CITIZENSHIP INFORMATION

Are you a US Citizen? Yes No
If you are not a US Citizen, please answer the following questions regarding immigrant status and Visa type.
Yes No US Immigrant/Permanent Resident Alien
Yes No Visa holder
If Yes, Visa type: F1 F2 J1 J2 HIB
Visa classification: Student Research Scholar Other, specify:______
Visa holders must complete the International Graduate Student Supplemental Application form. Link to form
Are you a Pennsylvania resident?
Yes, more than one year Yes, less than one year No

CITIZENSHIP INFORMATION (cont.)

The following three questions are REQUIRED by the University of Pittsburgh.
Is your father a resident of Pennsylvania?
Yes, more than one year Yes, less than one year No NA
Is your mother a resident of Pennsylvania?
Yes, more than one year Yes, less than one year No NA
Is your guardian a resident of Pennsylvania?
Yes, more than one year Yes, less than one year No NA

PHONE INTERVIEW

All external applicants need to schedule a phone call with the Associate Program Director, Dr. Amber Barnato, to discuss research interests prior to preparing the list of 2-5 potential mentors. In order to schedule an interview with Dr. Barnato, please follow the instructions below:

1.  An interview calendar has been created at the website: http://doodle.ch/nqrqhgp2v425i267.

2.  After clicking on the link you will see a calendar with interview dates and times listed.

a.  Type your name in the “Your Name” box.

b.  Choose the date and time for your phone interview by clicking in the box underneath your preference. Please note that only one applicant may be scheduled in each interview slot. If you see a green “OK” box in any row above your preference, or if the “Count” located at the bottom of the calendar equals “1” below your preference then that interview appointment time has already been chosen and you will need to choose a different date and/or time. Once you have checked the box of your preference, please click “Participate.”

3.  If your phone interview is scheduled for a Thursday evening or Saturday morning, please call 412-443-4559.

If your phone interview is scheduled for a Friday afternoon, please call 412-692-4875.

PERSONAL STATEMENT ADDENDUM

All students will have completed a common application through the Doris Duke Clinical Research Fellowship website, which includes a personal statement describing prior research experience, career goals, and the areas of clinical research in which you are currently interested. For your University of Pittsburgh addendum, please list the names of two to five federally-funded University of Pittsburgh clinical researchers and a very brief (2-3 sentence) description of the research that they conduct which interests you.

Signature/Certification of Accuracy

I certify that the information provided on this application form and supporting documentation is accurate and correct. I understand that providing false and misleading information is just cause for disqualification for admission or dismissal from the University of Pittsburgh. If enrolled as a student, I agree to abide by the rules and regulations set forth by the University of Pittsburgh as they are at the time of my admission or as they may change during my continuance as a student.

Electronic applications do not need to be signed. Checking the box below is considered equivalent to your signature.

I certify that the information provided in this application form is accurate and correct. I understand that providing false and misleading information is just cause for disqualification for admission or dismissal from the University.

The University of Pittsburgh values equality of opportunity, human dignity, and racial/ethnic and cultural diversity. Accordingly, the University prohibits and will not engage in discrimination or harassment on the basis of race, color, religion, national origin, ancestry, sex, age, marital status, familial status, sexual orientation, disability, or status as a disabled veteran or a veteran of the Vietnam era.