APPLICATION FOR THE FASEB SRC #11677 TRANSLATIONAL NEUROIMMUNOLOGY PRE-MEETING WORKSHOP FOR TRAINEES. You may not apply for a FASEB MARC travel award if you are receiving funding from any other source related to the FASEB SRCs. The travel award is not transferable without proper documentation and authorization.
DEADLINE INFORMATION: All applications for FASEB MARC Travel Awards must be received no later than JUNE 10, 2016 for the FASEB SRC #11677 Translational Neuroimmunology Pre-Meeting Workshop. Late and/or incomplete applications will not be processed.
Please provide the Science Research Conference information requested below:
SRC: TRANSLATIONAL NEUROIMMUNOLOGY PRE-MEETING WORKSHOP FOR TRAINEES (July 24, 2016)
SRC Web ID Number: Enter Web Id Number (12345-023) [You must pay the full SRC registration fee prior to applying.]
POSTER/PLATFORM (ORAL) PRESENTATION TRAVEL AWARD APPLICANT (must be FIRST AUTHOR and presenting at the meeting.)
Applicant Eligibility Category: (Postdoc, Advanced PhD Student ONLY)
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
EMail: Enter E-mail Address TEL: Enter Contact Phone# MOBILE: Enter Mobile#
Home Address: Enter Address
City: Enter City State: Enter State Code ZIP: Enter ZIP Code
1) Are you an individual from a background or group identified as being underrepresented in the biological and behavioral sciences? (required)
2) Please indicate Underrepresented Group (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 Ethnicity Or Underrepresented Group
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) Student/Trainee: What is your Final Career/Long-term Terminal Degree Desired: (required)
If “Other” selected, enter other degree: (required) Specify Other
6) Are you planning to pursue a career in biomedical research? (required)
7) Select the number of days you are planning to attend the SRC/Workshop? (required)
8) Are you a FASEB Society Member?
If “Yes,” indicate Society:
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.
ABOUT THE FASEB MARC TRAVEL AWARDS: FASEB is offering a limited number of travel awards for underrepresented postdoctoral fellows and advanced PhD students to help defray pre-meeting registration and travel-related expenses associated with FASEB SRC #11677 Pre-Meeting Workshop attendance. These funds are meant to defray meeting registration, air, ground, lodging/subsistence expenses only. NOTE: Travel awards are processed as reimbursements after the meetings. Original receipts will be required in order to receive reimbursement. The maximum amount to be reimbursed for meeting registration/travel-related expenses will be indicated in the travel award recipient’s award letter. Please read the Rules for Reimbursement completely prior to securing your travel arrangements.
ADVANCED PhD STUDENTS AND POSTDOCTORAL FELLOWS 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 legal documents will be required to verify proof of USA citizenship/permanent resident status: 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) Advance register for the FASEB SRC #11677 Pre-Meeting Workshop attendance in addition to the FASEB SRC #11677 “Translational Neuroimmunology: From Mechanisms to Therapeutics”. Follow abstract submission guidelines.
3) Submit your abstract and appropriate materials by the deadline date. NOTE: Complete FASEB MARC Travel Award Application packets must be received no later than JUNE 10, 2016 at 5:00 PM EDT.
4) Complete and submit this application form including:
a. A copy of your accepted FASEB SRC abstract. NOTE: Abstracts submitted for FASEB SRCs are automatically accepted for the conference program unless they are rejected after review by the FASEB SRC organizers.
b. A letter on departmental letterhead signed by your mentor, chair or dean that affirms your postdoctoral fellow or advanced PhD student status and your request for consideration for a FASEB MARC Travel Award. Be sure to include the email address and daytime phone number of your mentor, chair or dean.
c. A current copy of your CV/resume including all sources of funding you are receiving/have received.
d. A one-page statement detailing the benefit you will receive by participating in the pre-meeting workshop, in addition to presenting and discussing your research at the meeting.
The FASEB MARC Program review committee will select the award recipients based on the accepted scientific abstracts of 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 new/first-time FASEB MARC Travel Award applicants. Applicants selected to receive a travel award will be notified by the FASEB MARC Program upon approval of their application.
SUBMIT APPLICATION TO: FASEB MARC Program, 9650 Rockville Pike, Bethesda, Maryland 20814-3998; Tel: 301-634-7109; FAX: 301-634-7353; eMAIL: ; Internet: http://www.faseb.org/marc
The FASEB MARC Program is funded by a generous grant from the National Institute of General Medical Sciences, National Institutes of Health. T36-GM008059-32 NCE.
TRAVEL AWARD APPLICATION CHECKLIST
Completed Travel Award Application FormCopy of Confirmed Conference Registration for the FASEB SRC
Copy of Accepted/Programmed Abstract
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 receive/have received
One-page statement detailing the benefit you will receive by participating in the meeting.
** If USA Citizen, a copy of one of the following is required: 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
If applicable, include disability statement and ADA-related reasonable accommodation request.
PLEASE BE ADVISED,
WE DO NOT ACCEPT PIECEMEAL SUBMISSIONS.
ALL INCOMPLETE AND/OR LATE APPLICATION PACKETS
WILL BE DECLINED UPON RECEIPT.