2016 PECTS Program Application

University of Illinois at Chicago

CCTS Pre-doctoral Education for Clinical and Translational Scientists Program

/ 2016 PECTS Award Application
University of Illinois at Chicago
CCTS Pre-doctoral Education for Clinical and Translational Scientists Program
Full Legal Name (Last, First, Middle)
Indicate other name(s) you have used on any documents you will be using in support of this application
(Last, First, Middle)
Prior Degrees
Current Degree Program
Department
College
Date Passed Qualifying Exam
Contact and Background Information
Current Mailing Address
Number and Street, Apartment Number or Mail Code
City, State, Zip Code
Phone Number / Alternate Phone Number
Email (we will use this address to contact you throughout the application process)
Citizenship (check one)
U.S. Citizen (born or naturalized) or U.S. Permanent Resident
Not a US Citizen or Permanent Resident
Gender (check one) Male Female
Race/Ethnic Group (optional)
Native or Alaskan Native
Asian or Pacific Islander
Black or African American, not of Hispanic origin
White, not of Hispanic origin
Other / Mexican American
Puerto Rican
Cuban
Other Hispanic
Complete Professional/Graduate Degree History
Name of College/University / Location (City, State) / Field of Study / Degree / Date Awarded/ Expected
Complete Undergraduate Degree History
Name of College/University / Location (City, State) / Field of Study / Degree / Date Awarded
Employment History
Title / Institution / Location (City, State) / Month/Years
Employed
(From – To)
Awards and Honors
Year / Award / Institution
Attachments For specific directions for each item listed below, refer to the CCTS Pre-doctoral Education for
Clinical and Translational Scientists Program Announcement.
Brief Letter from Director of Graduate Studies about student standing, including qualifying/preliminary exam status
Personal Statement (1 page max)
Dissertation Proposal (2 pages max)
Curriculum Vitae
First Letter of Recommendation (from dissertation advisor)
Second Letter of Recommendation
Transcript(s), Professional/Graduate Level (Unofficial copies are acceptable.)
Department Administrative Contacts:
Home Department Name:
Department Business Manager (Name, Email Address, Phone Number):
Department HR Contact Person (Name, Email Address, Phone Number):

I understand that giving false information, or withholding information, may make me ineligible for participation in this program. I have read this application and certify that the statements I have made on this application are correct and complete.

Signature

Date

Deadline: Applications must be received by July 18, 2016

Only complete applications will be considered. Submit the signed application form with required attachments scanned together into one PDF file (except for recommendation letters) to:

Samantha Bynum, MA

Program Coordinator

University of Illinois at Chicago

College of Medicine

Room 301, CSN

820 S. Wood Street

Chicago, Illinois 60612

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