Form 1 Application for Pharmacology Research Associate Program

OMB No. 0925-0378
Form approved through 8/31/07

U.S. Department of Health and Human Services
Public Health Service - National Institutes of Health

Application for
Pharmacology Research Associate Program
1. Full Name

2. For assignment beginning

Last:

First:

MI:

Year:

3. Present Home Address

4. Phone # (including area code)

Street:

Primary:

City:

State:

Zip Code:

Work:

Country

Cell

5. Education and Professional Training

Dates Attended

a. Undergraduate and Graduate
Names of all Universities, Colleges or
Profesional Schools Attended

Location
City

Major
State

From
Mo

Yr

To
Mo

Degree
Yr

Degree Conferred
Req
or to be
Fulfilled conferred
Mo

Yr

Mo

Yr

b. Other Postdoctoral Fellowships, Training, or Specialized Training

c. Professional Positions Held or Expected Prior to Duty at NIH

6. Membership in Honorary Societies
Phi Beta Kappa

Omicron Kappa Upsilon

Alpha Omega Alpha

Other

7. References
Please list below names and addresses of three physicians and/or basic scientists closely associated with your professional career who can
evaluate your clinical and research capabilities. You are responsible for requesting them to complete the enclosed evaluation forms.
Name

Street

City

State

Zip

(1)
(2)
(3)
Public reporting burden for this collection of information, including the Preceptor Selection Verification form, is estimated to average 480 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974., ATTN: PRA (0925-0378). Do not return the completed form to this
address.

NIH 2721-1 (8/04) Pg 1

Application for
Pharmacology Research Associate Program
(Continued)

8. Previous Research or Laboratory Experience
Date
Time Spent
Directed By

Date
Time Spent
Directed By

Date
Time Spent
Directed By

Date
Time Spent
Directed By

Date
Time Spent
Directed By

9. Publications

NIH 2721-1 (8/04) Pg 2

Research Problem

Application for
Pharmacology Research Associate Program
(Continued)

10. Type of career planned, research, academic objectives
Provide your research plan. Give short statements and use the following format:
1. Hypothesis/Specific Aims
2. Background and Significance
3. Research Design and Methods
4. Possible Outcomes/Alternative Approaches
These sections should not exceed 3 pages or 12,000 characters (total).

11. What special training or experience do you seek at NIH?
How will this experience relate to pharmacology? Give a short statement of the siginificance of your training and the proposed
research, and how it will prepare you to contribute to or advance the field of pharmacology.
This answer should not exceed 1 page or 4,000 characters.

• The applicant should discuss his/her plans and prepare these sections in consultation with an approved PRAT preceptor. While
collaboration with the sponsor is important, the responses should be written by the applicant.
• Provide sufficient detail in order to be evaluated for scientific merit and for training potential. Eligible preceptors and descriptions of
their laboratory research can be found in the PRAT Program brochure.
• Applications submitted without the preceptor's prior approval will not be accepted.
NIH 2721-1 (8/04) Pg 3

Attachment to application for the
Pharmacology Research Associate Program

12a. Requested Preceptor
Last:

12b. Lab Name/Institute
First:

MI:

13. Citizen of what Country 14. If other than the U.S., visa status 15. I certify that the above information is accurate
Check box to sign document electronically.
U.S.

Other

Signature

Date

Fact Sheet

NIGMS Training Website

How did you learn of the PRAT Program?
Poster
Other (please specify):

Preceptor

OMB No. 0925-0378
Form approved through 8 /31/07

Applicant Biographical Sketch
for Application to the
Pharmacology Research Associate Program
Name:

Position Title:

Education/Training:
(Beginning with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training)

Institution

City

State

Degree
(If Applicable)

Year

Field of Study

Research Publications:
List, in chronological order, the titles, all authors, and complete references to all publications during the past three years and to representative
earlier publications pertinent to this application. DO NOT EXCEED 25,000 CHARACTERS.

(Rev. 8/04)