6 Technical Intramural Research Training Award

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TECHNICAL IRTA FELLOWSHIP PROGRAM
PROGRAM APPLICATION
OMB No. 0925-0299
Expiration Date 9/30/2012
Respondent Burden

Instructions: Before you begin, you may want to review some helpful hints on using electronic forms and a statement about privacy.
After you fill out the application form below, press the [Preview] button at the bottom of the page and review your application for
accuracy.
Eligibility Criteria:
1. Candidates must have graduated from a fully accredited U.S. College or University with a Bachelors or Masters degree.
2. Candidates must be U.S. citizens or permanent residents.
Indicates a required field!

1. Personal Information
Name:

Mr.
First

Month/Day of Birth:

/

MI

Last

(mm/dd)
Format: [email protected]

E-mail Address:
To obtain a free e-mail address, click here

Permanent Address:

City:
State:

(DC for Washington D.C.)

Permanent Zip Code:
Permanent Home Phone:

Format: (999) 999-9999

Current Home Phone:

Format: (999) 999-9999

Citizenship Status:

US Citizen

If Permanent Resident:

Country of Citizenship

Alien Registration No.

2. Academic Information
Current School (or last
school attended):
Cumulative GPA:
School Grading Scale:
Note: If you select 'Other', please explain in Section 3, Coursework and Grades. Be sure to describe
your school's grading scale and your current cumulative average relative to that scale.
Academic Major:

Select

or

Degree Type:
Month and Year Degree
Received/Expected:

/

(mm/yyyy)

3. Coursework and Grades
Course Title

Grade

4. CV/Resume
You may copy and paste your curriculum vitae into this space. Minor reformatting may be necessary. Include education, relevant
research experience, scientific publications, honors and awards, etc.

5. References
Letters of recommendation will be expected from ...

Reference 1 (Name, Address, Phone, Email):
Name:

Mr.
First

MI

Last

Address:
Phone:
E-mail:

Format: [email protected]

Once your application is complete, an e-mail will be automatically sent to this reference requesting an online letter of
recommendation.

Reference 2 (Name, Address, Phone, Email):
Name:

Mr.
First

MI

Last

Address:
Phone:
E-mail:

Format: [email protected]

Once your application is complete, an e-mail will be automatically sent to this reference requesting an online letter of
recommendation.

6. Research Interests
1.
2.
3.

7. Cover Letter:
Include your research interests, career goals, and reasons for applying for training at the NIH.

How did you hear about this program? (Please select all that apply.)

Ad in a scientific journal (Nature, Science); please specify:
Ad in a student journal; please specify:
Ad in a meeting program
Exhibit at a meeting; please specify:
Career development/opportunities workshop
Flier
Poster
From a mentor or advisor
From an alumnus/alumna of the program
NIH representative visited school
Web search
Other; please specify:

Notice to all applicants:
Students are advised to ensure that all application information is accurate. False or inaccurate information contained in this application
may be grounds for denying your candidacy or removing you from the program.
Preview Complete Application

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Burden Disclosure Statement for Applicants –
Public reporting burden for this collection of information is estimated to average 45-minutes for
the application and 45-minutes for the supplemental material 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 (0925-0299). Do not return the completed form to this address.

Burden Disclosure Statement for References –
Public reporting burden for this collection of information is estimated to average 15-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 (0925-0299). Do not
return the completed form to this address.