Please note: Applications are due by April 8, 2009.

If you are selected to participate in the course, your participation will be announced by April 17, 2009.

The actual course dates are:  June 29 and June 30, 2009.

Contact and Degree Information:

name:

e-mail:

phone: - -

address:

city:

state: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

zip:

current position title:

departmental affiliation:

degree(s): PhD MD MD/PhD year obtained:

Physician/Scientists:

What percentage of your time is spent on research?

Postdocs/Fellows:

If you are a postdoc, who is your P.I.?

How many years have you been in your position?

Have you started applying for a faculty/research scientist postion?

Yes

No

When do you anticipate starting a faculty/research scientist position?

Postdocs:
Would you like to be considered for a scholarship?

Yes

No

If yes, explain why you can not cover your course fees using lab funds, grant or fellowship funds:

Junior Faculty

How many years have you been in your position?

Are you currently the principal person responsible for managing your laboratory?

Yes

No

How many people do you supervise in your laboratory?

Postdocs:

Techs:

Grad & Undergrad Students:

Is your primary appointment in a basic science or clinical department?

Clinical

Basic

All Applicants:

Explain why you believe this course will be help you to develop as a current or future leader of a research group. Please tell the committee enough so we can understand why you want to take the course, but not more than 3-4 paragraphs.