CCTS2012 PredocSuppProgAppForm

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					                   2012 Award Application
                   University of Illinois at Chicago
                   CCTS Pre-doctoral Support for Translational Research 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 Preliminary 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)
    U.S. Permanent Resident – Alien Registration Number: A#
Gender (check one)        Male       Female
Race/Ethnic Group (optional)
    Native or Alaskan Native                                          Mexican American
    Asian or Pacific Islander                                         Puerto Rican
    Black or African American, not of Hispanic origin                 Cuban
    White, not of Hispanic origin                                     Other Hispanic
    Other
2012 Award Application
University of Illinois at Chicago
CCTS Pre-doctoral Support for Translational Research Program



Professional/Graduate Degree History
                                                                                                       Date
       Name of College/University    Location (City, State)        Field of Study       Degree       Awarded/
                                                                                                     Expected




Undergraduate Degree History
                                                                                                       Date
       Name of College/University    Location (City, State)        Field of Study       Degree
                                                                                                     Awarded/




Employment History
                                                                                                 Month/Years
              Title                 Institution                Location (City, State)             Employed
                                                                                                 (From – To)




Awards and Honors
Year             Award                                         Institution




                                                    -2-
2012 Award Application
University of Illinois at Chicago
CCTS Pre-doctoral Support for Translational Research Program


Attachments       For specific directions for each item listed below, refer to the CCTS Pre-doctoral Support for Translational
Research Program Announcement.
       Nomination Letter Written by Dissertation Advisor and Co-signed by Director of Graduate Studies
       Personal Statement (1-2 pages)
       Dissertation Proposal (2-3 pages)
       Curriculum Vitae
       List of Dissertation Committee
       First Letter of Recommendation (from dissertation advisor)
       Second Letter of Recommendation (from a second mentor with clinical or translational research expertise)
       Additional Letters of Recommendation (optional)
       Transcript(s), Professional/Graduate Level (Copies are acceptable.)
       Transcript(s), Undergraduate Level (Copies are acceptable.)
       Source of external funding, amount of stipend, start/end dates, and contact info for UIC Dept. Fund Administrator




I understand that withholding information requested on this application, including attendance at
any other institution, or giving false information may make me ineligible for participation in this
program or subject to dismissal if awarded. I have read this application and certify that the
statements I have made on this application are correct and complete.


Signature

Date


Only complete applications will be considered. Submit this original, signed application form with required
attachments to:

Biruté Petrauskas, MEd
Program Coordinator
University of Illinois at Chicago
Center for Clinical and Translational Science
Room 302, Medical Center Administration Building
914 South Wood Street, MC595
Chicago, Illinois 60612




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posted:10/2/2012
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