Mentored Clinical Research Training Program

							                          Mentored Clinical Research Training Program
                                   Application Cover sheet
                                         Deadline: February 1, 2007


Please type or print legibly. This form must accompany your application package.

Name:
        Last                             First                                Middle Initial

Department(s):

Professional title(s):

Work phone:                     Pager:                Fax:

Preferred email address:

Permanent mailing address:

Home phone:

Date of birth:

Research interest:

Letters of Support: Please list the name, title, affiliation and phone number for each letter writer.

        Name                             Title                Affiliation                      Telephone

1.

2.

3.

Checklist of materials:

Candidates must submit a formal written application with the following components:

        Application Cover Sheet
        Research Proposal (2-4 pages maximum) including a statement of work already completed on
        the project if any and an assessment of future mentored work.
        Curriculum Vitae
        Career Development Goals
        Mentoring Plan
        Letters of support from
                 Mentor (including specific mentoring commitment)
               Department Chair (including commitment of release time)


                 Send all application materials by February 1, 2007 to Glynis Butler-Stone
                                  glynis.butler-stone@ucdmc.ucdavis.edu