Cancer Prevention Research Training Program Postdoctoral Fellowship Application Checklist and Coversheet

Current or Previous Institution:

Division of Cancer Prevention & Population Sciences Cancer Prevention Research Training Program

P.O. Box 301439; Unit 1365 Houston, Texas 77030-1439

www.CancerPreventionTraining.org

Postdoc Application Checklist & Coversheet Page 1 of 2

Research and Career Statement: Not to exceed 2 pages. See application instructions for additional details. Letters of Support: One from EACH proposed mentor, signed and on letterhead, sent directly to Apply@CancerPreventionTraining.org). Copies can be included with this application.

Mentor's Profile Form

Mentor(s)' NIH Biosketch: One from EACH proposed mentor listed above.

Institution:

Application Checklist & Coversheet (this form signed & dated)

Complete this section if you are a foreign national holding a valid and appropriate visa. Due to fellowship time constraints, the applicants must already be in the United States to be eligible.

Visa Expiration Date MM/DD/YY:

Residential Status

Three letters of recommendation, signed, dated, and on letterhead, from external recommenders. These ORIGINAL letters should also be submitted separately and directly from the recommender to Apply@CancerPreventionTraining.org. Copies can be included with this application.

Home Country:Visa Type:

MD Anderson hire date (if applicable) MM/DD/YY:

Institution:

Date:

Full Legal Name:

Permanent Address:

Zip/Postal Code:

Personal Email: (Yahoo,Gmail,Hotmail)

Cell Phone:City/Town: State/Province:

Recommender Name #1:

Recommender Name #2:

Resume or Curriculum Vitae (CV): Include GPA, graduation & employment dates, titles of thesis and/or dissertation, and publications with PMCID.

GRE Test Scores (MCAT if applicable; copies are acceptable.)

Transcripts. All unofficial transcripts or copies of all official transcripts are acceptable. (UT School of Public Health applicants: Make sure you request transcripts which include instructor comments.) If you are awarded the fellowship, you will be asked to provide official transcripts. High school transcripts are not required.

CPRTP Fellowship Requirements Memo (must be signed by primary mentor only)

Recommender Name #3:

CPRTP Mentor Requirements Memo (must be signed by both the applicant and primary mentor).

Current or Previous Department:

Preferred Name:

Name:

Name:

Name:

Dept:

Dept:

Dept:

Institution:

Institution:

Institution:

If there are no test scores, indicate the reason:

Credential Evaluation (Copy). Note: This is applicable only if your qualifying degree was obtained from an institution outside of the U.S.

Completion date of qualifying advanced degree (Ph.D., PharmD, etc.) MM/DD/YY:

Visa copy. Include a legible photocopy of your valid visa (if applicable).

Select a Fellowship:

Country:

Qualifying degree type:

Alternate Email:

Caring Integrity Discovery

Dept:

Dept:

Proposed Primary Mentor:

Name: Institution:Proposed Co-Mentors:

Institution:

Mentor(s)' Other Support: One from EACH proposed mentor listed above.

Headshot photograph (with neutral colored background). Note: This can be a selfie or professional photo and will be used for our trainee photo roster.

Updated: 11/13/2017

APPLICATION COMPONENTS: Please check each box, complete any required fields, sign, print and scan this checklist and include as the cover sheet to the fellowship application.

Applicant's Signature Date:

CPRTP Staff Signature Date:

Education Coordinator Signature Date:

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REQUIRED SIGNATURES: ONLY the applicant's signature is required at the time of submission. The Education Coordinator and another member of the CPRTP staff will sign this form after our office receives the complete application.

For your information, the following additional documents will be required by MD Anderson Academic Visa Administration department (AVA) if you are awarded a fellowship by the Cancer Prevention Research Training Program (CPRTP): ·Immunizations: All immunizations (MMR, Chicken Pox, TB Skin Test, Tdap) must be current. TB Skin Test must be current within one year of the application submission date. Since obtaining a TB test and reading takes a minimum of 3 business days, it is recommended that this is completed at the time of application. Failure to comply with the immunization deadline set by CPRTP could delay the fellowship start date. Please note there is a $30 processing fee (price subject to change) to upload your immunization and health forms into CertifiedProfile.com. All immunization requirements are listed on the instructions form available to awardees via the Discover system. ·Personal and Criminal History Background Check ·Proof of Selective Service Registration, if applicable ·Proof of Enrollment (if applicable) ·Export Control Review Form ·Credential Evaluation, if highest degree is from outside the US. ·Official Transcripts from all institutions post-high school. Must include a certified translation if not written in English. Official transcripts may also be used to verify completion of a qualifying degree. ·Tobacco and Drug Screening: All educational appointees are required to complete a tobacco and drug test screening. Fellows who do not meet this contingency will not be eligible for an educational appointment at this institution, and the fellowship offer will be withdrawn.

ADDITIONAL REQUIRED DOCUMENTS

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Instructions: 1. Type in all requested data into this checklist. 2. Print this checklist & all requested documentation listed on the APPLICATION INSTRUCTIONS. 3. SCAN the completed & signed checklist and all requested documents in order, into ONE PDF DOCUMENT. 4. E-mail your stitched application to: Apply@CancerPreventionTraining.org. 5. The subject line & file name of your single PDF must be "Last Name, First Name - Postdoc Application".Please note that the Cancer Prevention Research Training Program (CPRTP) will evaluate your application and select awardees based on preset application criteria. Selected applicants will be invited to submit a research and career proposal. Once this submitted proposal is approved by the CPRTP Advisory Committee, processing by the MD Anderson Academic and Visa Administration (AVA) department will take approximately three to four additional weeks for processing. Once processing is complete, the awardee will begin their fellowship and receive funding. Processing is contingent upon submission and approval of all CPRTP application and Discover documents.

Postdoc Application Checklist & Coversheet Page 2 of 2

Father's highest degree earned?

Mother's highest degree earned?

Are you the 1st in your immediate family to graduate from college?

If additional ethnicities apply, please type:

Regardless of your answer to the prior question, please select one or more of the following ethnicities that best describes you:

Are you Hispanic or Latino (including Spain)?

DEMOGRAPHICS: Please answer the optional questions below. This information is used solely for reporting purposes to the funding agency & will not be used in a discriminatory manner.

Preferred language: Primary Language spoken at home:

Please select your gender:

___________________________________________________________________________________

Do you qualify as an individual from a disadvantaged background based on the following federal criteria?: (1) Come from an environment that inhibited the individual from obtaining the knowledge, skill and ability required to enroll in and graduate from a health professions school; or (2) Come from a family with an annual income below a level based on low-income thresholds according to family size published by the U.S. Bureau of the Census, periodically published in the Federal Register.

KEYWORDS: Please provide six (6) keywords that best describe your proposed research proposal, if this application is selected.

1

4

2

5

3

6

Caring Integrity Discovery Updated: 11/13/2017