Form 27 Academy Enrichment Application

NIH ACADEMY ENRICHMENT PROGRAM APPLICATION
OMB Clearance Number: 0925-0299
Expiration Date: 30-Jun-2019

Indicate your current status:*

First Name (Given Name):*

Last Name (Family Name):*

NIH or University E‑mail Address:

Permanent E‑mail Address:

Letter of Interest:

Describe your specific career goals and how a year (or two) of research at NIH will help
you reach those goals.

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights
of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties
for not participating or withdrawing from the study at any time. The information collected in this study will
be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the
study. Information provided will be combined for all participants and reported as summaries.