Form 1 Award Certificate Registration Collection

GRADUATE STUDENT AWARD CERTIFICATE

OMB Number: 0925-0740 (Expiration Date: May 2019)
Public reporting burden for this collection of information is estimated to average 5-minutes per
submission. 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 0925-0740. Do not return the completed form to this
address..
In order to receive your graduate award certificate for this period, you must have graduated or defended
your dissertation by DATE, and you must complete the following:
1) Complete and submit this online form
2) Register in the Alumni Database

GENERAL INFORMATION
First Name (Given Name):*

Last Name (Family Name):*

Your NIH Email Address:
Enter your active or inactive NIH email address.

Your Permanent Email Address:*

GRADUATE UNIVERSITY INFORMATION
Graduate University*
Enter the complete name of your graduate university.

Graduate School / College Name:
example: School of Medicine, College of Natural Science, etc...

Graduate Department / Program*
example: Department of Chemistry

Your Graduate University Start Date:*

(best estimate is acceptable)

Your Graduate University Graduation Date (actual or anticipated):*

Degree Awarded / Anticipated:*

Dissertation Title*
Use mixed case - i.e. capitalize each word other than 'a', 'the', 'from', 'of', 'at', prepositions,
etc...

NIH INFORMATION
NIH Institute-Center:*

NIH Campus Location:*

Your NIH Start Date as a PhD Graduate Student:*
(best estimate is acceptable)

Your NIH End Date as a PhD Graduate Student (actual or anticipated):*

NIH RESEARCH ADVISOR INFORMATION
NIH Research Advisor (Primary):*

NIH Research Advisor - Phonetic Pronunciation (Primary):*

NIH Research Advisor - Email Address (Primary):*

NIH Research Advisor (Secondary, if applicable):

NIH Research Advisor - Phonetic Pronunciation (Secondary, if applicable):

NIH Resarch Advisor - Email Address (Secondary, if applicable):

UNIVERSITY ADVISOR INFORMATION
University Research Advisor (Primary):
Include someone only if they are advising / mentoring you in research.

University Research Advisor - Phonetic Pronunciation (Primary):

University Research Advisor - Email Address (Primary):

University Advisor (Secondary, if applicable):

University Advisor - Phonetic Pronunciation (Secondary, if applicable):

University Advisor - Email Address (Secondary, if applicable):

CERTIFICATE AWARD
Name as you would like it to appear on the Award Certificate*

Write the phonetic pronunciation of your name:*

Do you plan to attend the award ceremony on DATE*
Yes

No

If you are unable to attend the ceremony, the certificate will be available for pickup
on the NIH Bethesda campus following the ceremony or mailed to you (provide your
mailing address in the space provided):

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