Name: Enter First and Last Name

DEADLINE INFORMATION: All application packets for sponsorship consideration must be received no later than Friday, August 28, 2015 (5PM EDT). Late and/or incomplete application packets will not be processed.

Applicant Eligibility Category: Select Applicant StatusPhD Student (3rd Yr)PhD Student (4th Yr)PhD Student (5th Yr)New Postdoc (1st Yr) (Advanced PhD Students – minimum 3rd year; New Postdoc- 1st year)

Name: Enter First and Last Name

Gender: Select GenderFemaleMale Title: Select TitleDr.Mr.Ms.Mrs.

Institution: Enter Institution's Name Department: Enter Department

Address: Enter Address

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

EMail: Enter E-mail Address TEL: Enter Contact Phone# MOBILE: Enter Mobile Phone#

Home Address: Enter Home 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? 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)Pacific Islander (Amer. Samoa)Other (** specify)

** 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"

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 is destroyed through a secure shredding process.

4)  Are you funded by any NIH-funded or NSF-funded programs at your university? Indicate Yes or NoYesNo

5)  Are you a FASEB Society Member? Indicate Yes or NoYesNo

If “Yes,” indicate Society: Indicate SocietyAAAAAIABRFACSMAFMRAMPAPepSAPSASBMBASCIASHGASIPASNASBMRASPETSee next list for additional societies Indicate SocietyBMESESGSAHCSISCBPSSDBSFGSPRSSRTS

If “No,” would you like to be contacted by a FASEB Society regarding membership? Indicate Yes or NoYesNo
If “Yes,” indicate Society: Indicate SocietyAAAAAIABRFACSMAFMRAMPAPepSAPSASBMBASCIASHGASIPASNASBMRASPETSee next list for additional societies Indicate SocietyBMESESGSAHCSISCBPSSDBSFGSPRSSRTS

Please list (voluntarily) any disabilities that would require the attention of the Institute’s organizers. List any device/services that would enhance your ability to participate. Please Explain in Detail

______

1)  Have you ever participated in the Compact for Faculty Diversity’s “Institute on Teaching and Mentoring”?

Select Yes or NoYesNo

2) Are you preparing for a career as a Faculty Member at a Teaching University/College? Select Yes or NoYesNo

3) What is/was your PhD degree conferral date? Enter Degree Conferral Date

ABOUT THE FASEB MARC SPONSORSHIP AWARDS: Through an agreement with the Compact for Faculty Diversity, the FASEB MARC Program is able to sponsor participation for 25 PhD students at the 2015 Institute on Teaching and Mentoring which will be held October 29- November 1, 2015 in Arlington, Virginia. The FASEB MARC Program PhD Student Sponsorships will provide full Institute registration including travel expenses (air travel, hotel lodging and meals) for the 25 selected participants.

NOTE: Upon Institute registration, travel/flight arrangements will be made for the participant by SREB (State Doctoral Scholars Program, the group managing the Institute) staff. Lodging arrangements at the host hotel will be made for the participant by SREB staff and will be based on double-occupancy. All meals, with the exception of the dinner meal on Saturday evening, will be provided as part of the Institute. Incidentals (telephone, Internet, valet, laundry, movies, room service, etc.) will be at participant’s own expense and will not be covered.

FASEB MARC Program Sponsorship: Institute registration payment for the selected participant will be made directly to the SREB. Reimbursement for participant’s Saturday evening meal and ground transportation (supported by receipts) to/from home and airport, and to/from host hotel and airport will be provided directly to the participant (as a reimbursement from the FASEB MARC Program) after the meeting.

Interested PhD Students (minimum 3rd year) and Postdoctorates (within 1st year) must meet the following criteria:

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)  Be a full-time advanced PhD student (minimum 3rd year) or recent Postdoctoral Fellow (within 1st year) who is recognized as being underrepresented in the biological or behavioral sciences at an accredited higher-learning institution.

3)  Be pursuing a PhD (or PhD recently conferred) in a discipline in the biological or behavioral sciences

4)  Career goals must include earning the doctoral degree and succeeding as a member of the professoriate at a teaching institute of higher learning.

5)  Be a member of one or more FASEB Member Societies.

6)  Be able to commit to 2 consecutive years of participation in the Institute on Teaching and Mentoring. (FASEB MARC Sponsorship is valid for 2 consecutive years.)

NOTE: Applicant must not be affiliated with or supported by any funds through the Southern Regional Education Board (SREB), the Western Interstate Commission for Higher Education (WICHE), the National Institutes of Health (Bridges to the Professoriate NIGMS-MARC), the National Science Foundation (Alliance for Graduate Education and the Professoriate), the Alfred P. Sloan Foundation and the Office of Federal TRIO Programs, United States Department of Education (Ronald E. McNair Program).

APPLY EARLY! DEADLINE: AUGUST 28, 2015 (5PM EDT.) Applications are reviewed and approved on a rolling basis. TO APPLY:

1)  Complete and submit this application form including all supporting documentation.

2)  Submit a current copy of your CV/Resume (including any federal funding support you receive.)

3)  Submit a one-page statement demonstrating financial need and identifying potential benefits to be gained and the anticipated effect this may have on your planned teaching or teaching/research career.

4)  Submit a letter of 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.

5)  Submit any required documentation (copy of green card, tribal affiliation certificate, USA Passport ID page, etc.)

All applicants must be approved by the FASEB MARC Program review committee. The FASEB MARC Program review committee will select the sponsorship recipients based on 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.) In addition, preference will be given to FASEB Society members.

Applicants selected to participate in this 4-day program will be notified by the FASEB MARC Program upon approval of their application. Additionally, award recipients will be contacted by the SREB to complete registration for the Institute on Teaching and Mentoring.

SUBMIT APPLICATION TO: Complete application packets may be submitted via e-mail at , or via USPS: FASEB MARC Program; ATTN: Compact for Faculty Diversity; 9650 Rockville Pike; Suite L-6205, Bethesda, MD 20814-3998. FAX: 301.634.7353. For more information, please contact Ms. Cordelia Adams at , 301.634.7930.

The FASEB MARC Program is funded by a grant from the National Institute of General Medical Sciences, National Institutes of Health. (T36 GM-08059-32)

SPONSORSHIP AWARD APPLICATION CHECKLIST

Completed Sponsorship/Travel Award Application Form
Copy of CV/Resume (including all sources of fellowship/scholarship funding)
One-page Statement demonstrating financial need and identifying benefits to be gained.
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.)
** 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.