Application for Keystone Symposia
Early Career Investigator Travel Award (ECITA)
Eligibility Requirements – Applicant must meet ALL of the following eligibility requirements:- Applicant must be a United States citizen or Permanent Resident.
- Applicant must be a member of a federally designated underrepresented (UR) population, which includes African American, Hispanic/Latino, American Indian/Alaskan Native, Hawaiian
Native/ Pacific Islander - Applicant must be an assistant professor or equivalent scientist in industry, be no greater than four (4) years into appointment, and engaged in full-time laboratory research.
In addition to the above requirements, applicants are asked to consider mentoring a student or postdoc from a UR population for a one (1) year period beginning after attendance of the research meeting of interest. This student should not be one already currently being mentored and should not be scheduled to graduate prior to the year of the applicant’s potential mentoring period.
I hereby certify that information and documentation included in this application is true and correct.
Signature ______
Date ______
(Please print)
First Name ______
Middle Name ______
Last Name ______
Date of Birth (month/day/year) ______
Gender: _____ Male _____ Female
Ethnic Identity (check one):
_____African American/Black_____Hispanic/Latino
_____Native American/Alaskan Native_____Pacific Islander/Native Hawaiian
Citizenship (please check one):
_____United States Citizen_____ Permanent Resident
Home Address
Street ______Apt/Unit # ______
City ______State ______Zip Code ______
Telephone
Cell:(_____) ______- ______Office(_____) ______- ______
Email Address
Work______
Alternate ______
Employment Information
Institution Name ______
Department ______
Street ______
Suite/Mail Drop # ______
City ______State ______Zip Code ______
Position Title ______
Start date for this position ______
If you are currently in a training program:
Name of Training Program ______
Agency/Organization/University ______
City ______State ______Zip Code ______
Your Title ______
Start Date and Length of Time in Program ______
Program Office Telephone (______) ______- ______
Education Information
Undergraduate
Institution ______
City ______State ______Zip Code ______
Degree Earned: ______Year Received ______
Graduate (Doctorate)
Institution ______
City ______State ______Zip Code ______
Degree Earned: ______Year Received ______
Where did you complete your postdoctoral training?
______
Date completed ______
Additional Education (Master’s, etc.)
Institution ______
City ______State ______Zip Code ______
Degree Earned: ______Year Received ______
Do you have your own laboratory?_____ Yes_____ No
If yes:
Laboratory Name ______
Email Address ______
Institution/Organization ______
City ______State ______Zip Code ______
Telephone (______) ______- ______
How many of the following do you currently have employed in your lab (indicate number of each):
_____Postbac_____Graduate Student
_____Postdoc_____Assistant Professor
_____Research Scientist_____Undergraduate
Specific Research Area:
______
If awarded the Early Career Investigator Travel Award, what Keystone Symposia conference would you attend?
Conference Title ______
Conference Dates ______
Specifically state how this travel award will benefit your research at present:
______
What is the specific research question you are attempting to answer?(please be specific and state an actual question)
______
Have you ever attended a Keystone Symposia research conference?
_____ Yes_____ No
How did you hear about the Keystone Symposia Early Career Investigator Travel Award?
_____Colleague (please indicate name of colleague)
______
_____Prior ECITA awardee (please indicate name)
______
_____Keystone Symposia website
_____Professional meeting, including SACNAS, ABRCMS, or society meeting
_____Received email information
_____Other (please indicate)
______
Part of the philosophy behind this award program is that we wish to provide a mechanism by which to help address the national workforce capacity needed to increase participation in life and biomedical research by scientists from historically underrepresented backgrounds. Further, it is the goal of this initiative to impact the number of scientists progressing up the ladder to tenured academic appointments. If you are the recipient of this award, Keystone Symposia asks you to consider mentoring a student or postdoc in your laboratory from an underrepresented minority background for a period of one (1) year commencing with the end of the research meeting you will potentially attend. The knowledge transfer of ECITA awardees with more junior scientific talent will greatly contribute to the development of next-generation scientists.
_____I agree to mentor a student from a federally designated UR population in my laboratory.
_____I cannot agree at this time to mentor a student from a federally designated UR population in my laboratory.
Signature ______
Date ______
Please email this form and your research abstract (relevant to the proposed Keystone Symposia meeting you would like to attend) to the Director of the Diversity in Life Science Programs (DLSP), Dr. Irelene Ricks, between November 2-30 for Keystone Symposia meetings starting in February 2019. For meetings starting later in the year, please check our website the schedule. If you have questions, please contact Dr. Ricks at or (970) 262-2669. DO NOT submit your abstracts using the links on the Keystone Symposia website. All abstracts must be emailed to Dr. Ricks with your application.
Revised IPR/10/21/15
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