Form 1 ICRC Application

Introduction to Cancer Research Careers (ICRC)
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Application Deadline: Monday, Aug 14, 2017.
OMB No.: 0925-0046
Expiration Date: 07/31/2019
Collection of this information is authorized by the Public Health Service Act, Section 411 (42 USC 285a). Rights of the program applicants are protected by The Privacy Act of 1974. Participation is voluntary, and there are
no penalties for not participating or withdrawing from the application process at any time. The information collected in this application process will be kept private to the extent provided by law. You are being contacted
online to complete this instrument so that we can process your application expeditiously.
Public reporting burden for this collection of information is estimated to average 60 minutes per response for this application, 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 current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to: NIH, Project Clearance
Branch, 6705 Rockledge Drive, SC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0046). Do not return the completed form to this address.

Personal Information
Prefix:

*Primary Phone:

*First Name:

Middle Name:

*Last Name:

Secondary Phone:

*Primary Email :

Secondary Email:

Format: XXX-XXX-XXXX

Format: XXX-XXX-XXXX

*Date of Birth:

*Previous NCI Internships
Yes

*Emergency Contact Person:

*Citizenship Status

No

*Emergency Contact Number:

*Are you MARC Student?

Format: XXX-XXX-XXXX

Permanent Address

Domestic

Yes

International

No

Domestic

Temporary Address

*Address Line 1:

Address Line 1:

Address Line 2:

Address Line 2:

*City:

City:

*State/Province/Region:

State/Province/Region:

*Zip/Postal Code:

Zip/Postal Code:

*Country:

*If yes, expiration date of your award:

Country:

UNITED STATES

International

UNITED STATES

Academic Information/Educational History
NOTE: Please enter academic details beginning with your most recent education experience. Do not include high school academic history.
*School Name:

*Date of Attendance: From

*Date of Attendance: To

*Education Level:

*Year at Current Level:

*Degree:

-- Select --

*School City/State:

*School Grading Scale:

-- Select --

School Grade if Other:

-- Select -Primary Major if Other:

*Primary Major

*Cumulative GPA:

-- Select -Secondary Major:

*Date Degree Earned or Expected

Secondary Major if Other:

-- Select --

Add

School Name Dates Attended

School City/State

Education Level Year at Level

Degree

Grade Scale

GPA Major Secondary Major Degree Date

Action

Research Experience
You must have at least one demonstrated research experience. Please be as detailed as possible in the description of your research.

*Date of Experience: From

*Name of Mentor:

*Mentor Phone #:

*Hours Per Week:

*Research Institution:

*Date of Experience: To

*Brief Summary of Duties (500 Character Limits):

500 Character limits

Add
Name of Mentor

Mentor Phone #

Date of Experience

Hours Per Week

Summary of Duties

Research Institution

Action

No Matching records found

Work Experience
Note: If you choose to include work experience in your application, you must enter Start and End Date of Employment, Name of Supervisor, and Brief Summary of Your Duties. Otherwise, work
Experience information you enter will not be saved.
Place of Employment:

Name of Supervisor:

End Date:

Hours Per week:

Supervisor Phone #:

Start Date:

Brief Summary of Duties (500 Character Limits):

500 Character limits
Add
Name of Supervisor

Place of Employment

Supervisor Phone #

Start/End Date

Hours Per week

Action

Summary of Duties

No Matching records found

Publications:

Add
Place
of Employment
Description

Action

No Matching records found

Honors and Awards:

Add
Place
of Employment
Description

Action

No Matching records found

Professional Society Memberships:

Add
Action

Description

Other Skills:

Add
Action

Description

Personal Statement
*Please address the following points in your personal statement in 600 words or less (approximately 4000 characters):
• Why you are interested in cancer research
• What your career aspirations are
• Why you should be selected to participate in the ICRC Program

4000 Character limits

Diversity Statement
*Please explain how your participation would further the goal of the ICRC Program to encourage diversity in the biomedical research consistent with NIH's Notice of Interest in
Diversity (NOT-OD-18-210).

1000 Character limits

Document Upload
In order for your application to be complete, please follow these directions: Be sure to block out any sensitive or uniquely identifiable information before uploading
(e.g., Social Security Number, Date of Birth, Student ID Number).
• Upload all transcripts in PDF form. Unofficial transcripts will be accepted at this time; however official transcripts will be required for participants selected for the program.
• Resume/CV submission is not mandatory, but will be required for applicants selected for the program.
• Financial document must be uploaded if claiming financial disadvantage. Must upload most recent federal tax return form for self, or parents (if a dependent), and/or spouse (if applicable).
• All documents submitted must include the name of the applicant.
• Block out any sensitive information or uniquely identifiable information before uploading (e.g. Social Security Number, Date of Birth, Student ID, etc.)

*Transcript(s):
Choose File

Action

File Name

Resume(s):
no file selected

Choose File

Action

File Name

Financial Document:
no file selected

Choose File

Action

File Name

References
Reference letters should be written by individuals who have knowledge of your academic and career interests, abilities, accomplishments, and preparedness for scientific
research. Select someone who knows you well and can speak specifically on your behalf. Research mentors are recommended as a good starting point. Previous or current
professors or employers can also provide letters.
Upon submission of your application, an e-mail will automatically be sent to each reference requesting that he/she complete an online letter of reference.

Reference 1:

Reference 2:

*Name:

*Name:

*Institution:

*Institution:

*Address:

*Address:

*Phone Number:

*Phone Number:

*E-mail:

*E-mail:

Scientific Methodology
Choose what best reflects your interests and abilities. Up to three (3) different choices may be selected.
Analytical Chemistry

Behavioural Research

Biochemistry

Bioengineering/Nanomedicine

Bioinformatics

Bioinorganic Chemistry

Biology

Biomedical Science

Biophysics

Biostatistics

Cancer Biology

Cancer Prevention

Cellular Biology

Cellular Haematology

Cellular Immunology

Chemistry

Chemistry/Drug Design and Development

Computational Biology

Computer Science

Cytology

Developmental Biology

Drosophila Genetics

Epidemiology

Functional Genomics

Genetics

HIV Research

Health Disparities

Immunology

Inorganic Chemistry

Mathematics

Medicinal Chemistry

Microbiology

Molecular Biology

Molecular Genetics

Molecular Haematology

Molecular Radiobiology

Molecular Virology

Mouse Genetics

Neuroscience

Nuclear Radiochemistry

Nutrition

Oncology

Organic Chemistry

Pathology

Pharmacology

Physiology

Psychology

Public Health

Statistics

Structural Biology

Synthetic Organic Chemistry

Toxicology

Vaccine Development

Virology

Other (please specify below)

Molecular Immunology

If Other, please indicate:

Medical entity/Disease
Choose what best reflects your interests and abilities. Up to three (3) different choices may be selected.
AIDS/HIV

Adult Cancers

All Cancers

Alternative Medicine

Biomarkers, early detection

Bladder Cancer

Brain and Nervous System Cancer

Breast Cancer

Chemoprevention

Chemotherapeutics

Childhood Cancers

Colon and Rectal Cancer

Endometrial Cancer

Genetics

Immunology

Kaposi's Sarcoma

Kidney (Renal Cell) Cancer

Leukaemia

Lung Cancer

Lymphoma

Lymphoma, non-Hodgkin

Melanoma

Metastasis

Ovarian Cancer

Pancreatic Cancer

Prostate Cancer

Risk Factors

Skin Cancer (non-melanoma)

Susceptibility

Thyroid Cancer

Other (please specify below)

If Other, please indicate:

Internship/Placement Type
Tell us more about the type of internship you are seeking.
*Type of Placement Desired:

*Type of Internship Desired:
Summer

Post-Baccalaureate

Lab Placement

Non-Lab Placement

No Preference

If you selected Post-Baccalaureate, would you consider a Summer internship
if a Post-Baccalaureate position is not available?
Yes

No

*Research Discipline: (check no more than two options)
Biomedical (Basic Research)
Biomedical (Clinical Research)
Health Disparities
Epidemiology
Public Health
Other (please specify below)
If Other, please indicate:

Where did you hear about this program?
Where did you hear about this program?
Faculty Member at your school
NIH or NCI website
Scientific Conference (please specify below)
Online Bulletin Board (please specify below)
Print Advertisement (please specify below)
Previous Participant (please specify below)
LinkedIn
Other (please specify below)
If Other, please indicate:

* I certify to the best of my knowledge and belief, all of the information in this application, attached to this application, and submitted subsequent to

this application is true, correct, complete, and made in good faith. I understand that false or fraudulent information on or attached to this application
may be grounds for not hiring me or firing me after I begin work. I understand that any information I give may be investigated.

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