Form 4 NAVW-NIH Visit Week Application

NIH VISIT WEEK
OMB No. 0925-0299
Expiration Date: August 31, 2016
Respondent Burden

Below is the application for the NIH Visit Week. This application must be completed and submitted by
DATE. Before submitting, carefully review your information to ensure accuracy, especially contact
information. Once the application is submitted, your reference will receive an email with instructions
on electronically submitting the recommendation letter. We encourage you to follow-up with your
reference to ensure the recommendation request was received. It is your responsibility to ensure the
letter of recommendation is submitted by the reference deadline - DATE.

PERSONAL INFORMATION
Title: *

First Name (Given Name):*

Last Name (Family Name):*

CONTACT INFORMATION
E-mail Address:*
(check accuracy)

Phone Number:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

ACADEMIC INFORMATION
School Name:
(complete name, no acronyms)

School State:

Current Education Level:

Academic Major:

REFERENCE INFORMATION
Reference Title:*

Reference First Name (Given Name):*

Reference Last Name (Family Name):*

Reference E-mail Address:*
(check accuracy)

Reference Phone Number:

EDUCATIONAL HISTORY AND GOALS
Your Affiliation:

Describe your career, educational goals, and motivation for attending NIH visit week.
The NIH is committed to maintaining its stature as a premiere research institution by
building an inclusive workforce, fostering an environment that respects the individual, and
offering an opportunity for each person to develop his or her full potential in the pursuit
and support of science. We welcome trainees of all genders, races, ethnicities, physical
abilities, and socioeconomic backgrounds.

Provide a brief list of your research interests, example: particular disease, condition,
etc...
(limit 150 character, including spaces)

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