Form 11 NHMA Application Form

OMB #0925­XXXX
Expiration Date: XX/XXXX
NIDDK-National Hispanic Medical Association (NHMA) Application
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National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
National Hispanic Medical Association (NHMA)
Travel Award Application for NIDDK/NHMA Fellows Attending
the NHMA Annual Conference

APPLICANT INFORMATION
Date
FULL NAME
Last Name

First Name

M.I.

Graduate Degree(s)

ORGANIZATION ADDRESS
Name of Organization
Street Address
City

State

Zip Code

State

Zip Code

PERMANENT ADDRESS
Street Address
City
Phone Number

Email Address

The primary use of the information collected on this form is to support the application process for the NIDDK-NHMA Travel Awards Program offered through
the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
PageNational
1 of 3 Institutes of Health (NIH). If you voluntarily complete this form and
send it by e-mail, you are advised that e-mail communications are not secure against interception and inadvertent disclosure. Please see the NIDDK Privacy
Statement, for more information.

CAREER INFORMATION
CAREER STATUS

☐Post Graduate Year

☐Assistant Professor

SPECIALTY

☐Acting Instructor

☐Resident

Primary Specialty

☐Fellow

☐Instructor
Secondary Specialty

DEMOGRAPHIC INFORMATION
WHICH OF THESE BEST DESCRIBES YOUR ETHNICITY (CHOOSE ONE)?
☐Hispanic or Latino
☐Not Hispanic or Latino
WHICH OF THESE BEST DESCRIBES YOUR RACE (CHOOSE ONE OR MORE)?
☐American Indian or Alaska Native
☐Asian
☐Black or African American
☐Native Hawaiian or other Pacific Islander

☐White

CITIZENSHIP STATUS?
☐U.S. Citizen
☐Noncitizen National

☐Permanent Resident of U.S. Pending

☐Permanent Resident of U.S.
GENDER
☐Female

☐Other

☐Other, U.S. Visa (specify)

☐Male

ADDITIONAL INFORMATION
HOW DID YOU HEAR ABOUT THIS OPPORTUNITY?
☐Academic Dean
☐Direct Mailing

☐Professional Organization

☐Word of Mouth

☐Email

☐Website

☐Training Program Director

☐Other (Specify)

ARE YOU A MEMBER OF THE NATIONAL HISPANIC MEDICAL ASSOCIATION (NHMA)?

The primary use of the information collected on this form is to support the application process for the NIDDK-NHMA Travel Awards Program offered through
the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH). If you voluntarily complete this form and
send it by e-mail, you are advised that e-mail communications are not secure against interception and inadvertent disclosure. Please see the NIDDK Privacy
Statement, for more information.

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PLEASE SUBMIT THE FOLLOWING WITH YOUR APPLICATION
•
•
•

Personal statement describing your research interest/s, career ambitions, and how attending
the program will influence your training and development
Curriculum Vitae
Letter of support from the Chairperson or Director of your academic training program
indicating how you will continue to be supported in your pursuit of a career in academic
medicine

PLEASE EMAIL APPLICATION TO [email protected]
The primary use of the information collected on this form is to support the application process for the NIDDK-NHMA Travel Awards Program offered through
the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH). If you voluntarily complete this form and
send it by e-mail, you are advised that e-mail communications are not secure against interception and inadvertent disclosure. Please see the NIDDK Privacy
Statement, for more information.

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