NOTE: You Must Be Confirmed to Participate in the Course Prior to Applying for a Travel Award

The FASEB Diversity Resources travel award program is intended to encourage and support participation of scientists from underrepresented groups in career-enhancing activities, courses and meetings. Successful applicants will receive support for course related expenses (i.e., travel, lodging, per diem etc.) up to a maximum of $1,000, including the registration fee, for both the AAI Introductory Course Part 1 and Part 2, (if only participating in 1 course, the maximum will be $500) or the AAI Advanced Course. Reimbursement after successful completion of the course will require original receipts and all requests must meet FASEB Diversity Resources Reimbursement Guidelines. Questions may be addressed to .

The FASEB Diversity Resources Registration/Travel Awardis not transferable without proper documentation and authorization. Travel awards are available for PhD/Graduate Students, Medical Students, Postdoctoral Fellows, Junior Clinical Fellowsand Early-Career Investigators ONLY.

DEADLINE INFORMATION: All complete application packets for a Travel Award must be received no later thanJune 15, 2018 (5PM EDT). Late and/or incomplete application packets will not be processed.

NOTE: You must be confirmed to participate in the course prior to applying for a travel award.

*indicates required response

* TYPE OF AWARD REQUESTED: Select Award RequestedFULL Travel AwardLOCAL Travel Award - Registration ONLY

* Please select the Immunology Course you wish to attend: Select Course Name/LocationIntroductory Course in Immunology: CA_Part 1 ONLYIntroductory Course in Immunology: CA_Part 2 ONLYIntroductory Course in Immunology: CA_Part 1 and 2Advanced Course in Immunology: MA

* Applicant Eligibility Category: Select Applicant StatusGraduate/PhD StudentPostdoctoral FellowMedical StudentJunior Clinical FellowEarly_Career Investigator

* 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 Fax#

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 Diversity Resources travel award recipients? Select YES or NOYESNO

ABOUT THE UNDERREPRESENTEDSCIENTIST/TRAINEE AWARDS: APPLY EARLY!! FASEB is offering awards for eligible underrepresented trainees and early-career investigators to help defray course registration, room and board, and/or travel-related expenses associated with the Introductory and AdvancedCourses in Immunology. These funds are meant to defraythe cost of course registration, lodging, air/ground transportation expenses, and travel day per diem allowance only (if applicable). Full-time trainees and early-career investigators(who are identified as being from a group considered underrepresented in the biomedical, clinical and behavioral sciences) are eligible to apply for the awards. Full-time trainees and early-career investigators at accredited minority institutions are also eligible to apply for trainee awards. These are federally-funded awards and are restricted to USA Citizens/Legal Permanent Residents of the USA.

Type of awards available include: 1)Full Travel Award 2) Local area Travel Award – Registration ONLY

Award Amount: The amount of the Full award is up to $1,000 (or up to $500 for only Part 1 or only Part 2 of the Introductory Course in Immunology) maximumfor course participation and must be applied to related expenses including travel (air and ground transportation) and course registration and/or room and board for applicants who are approved to participate in the course and receive approval for the FASEB Underrepresented Scientist/Trainee Award. The amount of the Local area award is up to maximum amount for the course registrationfee for applicants who are approved to participate in the course and receive approval for the FASEB Underrepresented Scientist/Trainee Award. 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 travel-related expenses will be indicated in the award recipient’s award letter.

The FASEB Diversity Resources are funded by grants from the National Institute of General Medical Sciences, National Institutes of Health. R25 GM116706 and T36 GM008637

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, clinical and behavioral sciences? * Select YES or NOYESNO

2) Please indicate Underrepresented Group * Select Underrepresented GroupDisability: Mental ImpairmentDisability: Physical ImpairmentDisadvantaged Background: Undergraduate ONLYEthnic: 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,

3) 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 MARC Program staff, the documents are destroyed through a secure shredding process.

4)Have you ever attended an AAI Introductory or Advanced Course in Immunology or a similar/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)What is the total number of days you are planning to attend the course? * # of Days (exclude travel days)01233.545678

8)Are you an AAI Member? * Indicate YES or NOYES. I am an AAI Member.NO

9)If you are not an AAI member, are you a FASEB Society Member? * Indicate YES or NOYES. I am a FASEB Society Member.NO
If “Yes,” indicate FASEB Society: * Indicate SocietyAAAAAIABRFACSMAFMRAGEAMPAPSAPepSASBMBASCIASHGASIPASNASBMRASPET(See next list for additional societies)* Indicate SocietyBMESESGSAHCSISCBSDBSEBMSFGSFRBMSPRSSRTPSTSUSHUPO(See next list for additional societies)

Americans with Disabilities Act - For Applicants Who Self-identified as “Disability: Mental” or “Disability: Physical” as an Underrepresented Group in #2 above: An individual with a physical or mental impairment that substantially limits one or more major life activities is eligible to apply for this travel 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 selected scientific meeting. Please explain in detail.

The FASEB Diversity Resources are funded by grants from the National Institute of General Medical Sciences, National Institutes of Health. R25 GM116706 and T36 GM008637

PhD/GRADUATESTUDENTS, MEDICAL STUDENTS, POSTDOCTORAL FELLOWS, JUNIOR CLINICAL FELLOWS AND EARLY-CAREER INVESTIGATORSWHO WISH TO BE CONSIDERED FOR AWARD FUNDING MUST:

1)Be a USA Citizen or a Legal Permanent Resident of the USA. (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” is required.)

2)Register for the course.

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

4)Submit an updated CV/Resume (including any federal funding support you receive).

5)Submit a copy of the Registration Confirmation/Approval Letter Authorizing Participation in the Course.

6)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 research career.

7)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.

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

All award applicants must be approved by the FASEB Diversity Resources Program review committee. The FASEBDiversity Resources Program review committee working in partnership with AAI leadership/staff will select the award recipients based on the applicants’ written statements of financial need, benefits to be gained by participating in the course, and 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.) Members of AAI will be given preference.Funding for the awards is contingent upon funding availability.

Applicants selected to receive a travel award will be notified by the FASEB Diversity Resources Program staff upon approval of their application.

SUBMIT APPLICATION TO: FASEB Diversity Resources Program Manager at ,or via USPS: FASEB MARC Program; ATTN: FASEB Underrepresented Scientist/Trainee Award-AAI; 9650 Rockville Pike; Suite L-6412, Bethesda, MD 20814-3999.

The FASEB Diversity Resources are funded by grants from the National Institute of General Medical Sciences, National Institutes of Health. R25 GM116706 and T36 GM008637

FASEB UNDERREPRESENTED SCIENTIST/TRAINEE AWARD APPLICATION CHECKLIST

Completed Award Application Form
Copy of Registration Confirmation/Approval Letter Authorizing Participation in the Course.
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 an incomplete submission.)
Copy of CV/Resume including all sources of funding you are receiving/have received.
One-page statement demonstrating financial need, identifying potential benefits, etc.
** If USA Citizen, copy of one of the following: 1) USA Passport ID Page, 2) Birth Certificate, 3) Certificate of
Naturalization, 4) Certificate of United States Citizenship, or 5) Consular Registration of Birth Abroad Form.
** If Legal Permanent Resident, copy of ‘Green Card’
** If American Indian/Native American, copy of Tribal Affiliation Certificate
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.

For information about the travel/registration awards for the 2018 AAI IMMUNOLOGY COURSES

For assistance in registering and inquiries about the 2018 AAI IMMUNOLOGY COURSES

IMPORTANT INFORMATION: These awards are federally-funded and supported through the Training, Workforce Development and Diversity (TWD) Division of the National Institute of General Medical Sciences/National Institutes of Health (NIGMS/NIH). For the purpose of meeting the goals and objectives specified by the NIGMS TWD, individuals from groups underrepresented in the biomedical, clinical and behavioral sciences include:

• Individuals from racial and ethnic groups shown to be underrepresented in biomedical research including Blacks or African Americans, Hispanics or Latinos, American Indians (who maintain tribal affiliation or community attachment) or Alaska Natives, Native Hawaiians and other U.S. Pacific Islanders (Guam, American Samoa);
• Individuals with disabilities, defined as those with a physical or mental impairment that substantially limits one or more major life activities; and
• Individuals from disadvantaged backgrounds, defined as those from a family with an annual income below established low-income thresholds and those who come from an educational environment that has inhibited the individual from obtaining the knowledge, skills and abilities necessary to develop and participate in a research career. (Applies to undergraduate students.)

Qualified underrepresented groups must be citizens or non-citizennationals of the United States of America or must have been lawfully admitted to the United States of America for permanent residence and have in possession a permanent visa at the time of application. Applicants must possess a current/valid green card. Applicants must also reside within the U.S. or U.S. territories.

Underrepresented PhD/graduate and medical students and postdoctoral and junior clinical fellows meeting the citizenship /residency requirements at accredited majority institutions are eligible to apply for this travel award. Early-career investigators meeting the citizenship /residency requirements and who are full-time employees at accredited minority institutions are eligible for this travel award. Full-time PhD/graduate and medical students and postdoctoral and junior clinical fellows meeting the citizenship /residency requirements at accredited minority institutions are also eligible.