Form FDA 5012 Form FDA 5012 Traineeship Application

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

TRAINEESHIP APPLICATION

Form Approved: OMB No. 0910-XXXX
Expiration Date: Month XX, 20XX
See PRA Statement at the End of Checklist
Date of Submission (mm/dd/yyyy)

Please gather the following items BEFORE applying to the FDA Traineeship Program. Late and/or incomplete
applications will not be considered.
• Please review our program website for the:
– Online Application Instructions
– Applicant Online Application User Guide
– General applicant eligibility criteria for students, post-doctoral, and other scientists.
– See our frequently asked questions (FAQs) for more information.

REVIEW ASSIGNMENTS

Go to the Program online application website. Look at the available assignments that are open to apply to and select those that may

interest you.

Please give attention to the eligibility requirements for each assignment.

GATHER APPLICATION MATERIALS

Electronic copy of your Resume/CV in PDF format only.

Two references and their contact information.

Personal statement which outlines both your educational and professional experience, as well as what has driven you to apply to the FDA’s

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Traineeship Program. Address what you would bring to the FDA and how you believe this Traineeship will help you reach your short- and
long-term career goals. Please limit your statement to 3000 characters. Applicants will be able to submit different personal statements for
each assignment that they apply to so that the personal statements can be tailored by the applicants for the assignments.

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Electronic copy of your transcripts in PDF format. Unofficial transcripts are acceptable only if your official transcripts are unavailable

at the time of your application submission. Considered applicants will be required to submit their official transcripts before
they can be offered a start date. Only one file can be uploaded per application so either submit a transcript for the most relevant
degree or combine all transcripts into one file. Official transcripts can be emailed to the program from academic institutions here:
[email protected] If your academic institution does not send official transcripts via email, applicants must notify
[email protected] to obtain the address to mail your official transcripts.

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If you are a student, in addition to your official transcript you need to send a letter on official letterhead from the academic institution stating

that you are a student.

If your academic institution does not send official transcripts via email, applicants must notify [email protected] to

obtain the address to mail your official transcripts.

GATHER CITIZENSHIP DOCUMENTS

Green Card number, expiration date, and a scanned image of the card that can be uploaded, if you are not a U.S. Citizen.

Non-U.S. citizen applicants must have resided in the U.S. for three of the last five years at the time that their applications are submitted.

Contact us: Please contact the program coordinators at: [email protected] with questions or concerns.

NOTES

Do not include your Social Security Number on any of your application materials.

Files over 20 MB cannot be uploaded into the application.

The Program is not responsible for technical issues unrelated to the application database that may result in a late or incomplete application.

The application will reset if you leave the screen idle for 120 minutes.

Applicants will be able to save, exit, and return to their application/applicant online profile. Applicants will be able to review their applications

to each assignment before submission and will be able to view records of all the applications that they have submitted.

When an applicant submits a complete application, the system will provide a confirmation number and send application submission

confirmation emails. Applicants should retain the confirmation numbers and application submission confirmation emails (one per assignment
applied to).

If you do not receive a confirmation within one day of submission, please email the program office.

I HAVE READ AND UNDERSTAND THE FDA’S TRAINEESHIP PROGRAM ONLINE APPLICATION CHECKLIST.
Yes

No

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PSC Publishing Services (301) 443-6740

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PRIVACY ACT STATEMENT

Authority: The information collected in this form is provided to comply with the Privacy Act of 1974 for individuals seeking non-employee
student, post-graduate or senior scientist training opportunities from the Food and Drug Administration authorized under section 746(b) of the
Food, Drug and Cosmetics Act 21 U.S.C. ch. 9 § 301 et seq. This collection of information supports the necessary function of identifying, and
evaluating students, fellows and trainees to accept and manage application materials, evaluate applicants for fellowship and traineeship training
opportunities as well as accept applicants. FDA will disclose information to another Federal agency, to a court, or a party in litigation before a
court or in an administrative proceeding being conducted by a Federal agency, when the Government is a party to a judicial or administrative
proceeding. Disclosure of information is voluntary. However, not providing this information will prevent the processing of your application.
Additional details regarding FDA’s use of information is available online: Privacy Act and Website Policies. Information is covered by OPM/
GOVT-5 (Recruiting, Examining, and Placement Records).
PRA Info
This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*
The burden time for this collection of information is estimated to average 15 minutes per response, including the time to review instructions,
search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments
regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:
Department of Health and Human Services
Food and Drug Administration
Office of Operations
Paperwork Reduction Act (PRA) Staff
[email protected]
“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.”

CITIZEN INFORMATION
Non Citizen
Permanent Resident

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IF NON-CITIZEN, HAVE YOU RESIDED IN THE US 3 OF THE LAST 5 YEARS?
Yes

No

GREEN CARD #

PERSONAL INFORMATION

GREEN CARD EXPIRATION DATE COUNTRY OF BIRTH

FIRST NAME
PRIMARY PHONE

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US Citizen

MI
OTHER PHONE

LAST NAME
EMAIL

Domestic Address
ADDRESS 1
CITY

ADDRESS 2
STATE COUNTY

ZIP CODE

International Address
COUNTRY
ADDRESS 1

ADDRESS 2

CITY

PROVINCE

POSTAL CODE

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EDUCATION
Education Type
High School Student

Undergraduate Student

Graduate Masters Student

Doctoral Student

High School Degree

College Degree

CERTIFICATE PROGRAM TITLE

Masters Degree

Doctoral Degree

Post Doctorate

Certificate in Appropriate

Program with Minimum
30 Credit hours

DEGREE

DEGREE COMPLETED (mm/yyyy)

EXPERIENCE AFTER QUALIFYING DEGREE
COMPLETED OUTSIDE US
Yes Name of Institution
No

Name of Institution

FIELD OF STUDY

CUMULATIVE GPA (Enter in format 9.99)

PERSONAL STATEMENT

Post-Grad Experience
PREVIOUS OR CURRENT EMPLOYER
YEARS SINCE GRADUATED FIELD OF INTEREST
FROM HIGHEST DEGREE?
(Must be a number)

REFERENCES

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PREVIOUS OR CURRENT EMPLOYER POSITION OF EMPLOYMENT

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At least two reference are required for each Application, and no more than 3 are allowed.
Reference 1
TITLE

FIRST NAME

MI

LAST NAME

MI = (Middle Initial) (Optional)
COMPANY/ORGANIZATION

POSITION

RELATIONSHIP

YEARS KNOWN
(Must be a number)

PRIMARY PHONE

OTHER PHONE

ADDRESS 1
CITY

EMAIL
ADDRESS 2
STATE COUNTY

COUNTRY PROVINCE (Optional)

ZIP CODE
POSTAL CODE (Optional)
Add Reference

Remove Reference

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MILITARY EXPERIENCE
ARE YOU A VETERAN OF THE US ARMED FORCES?
Yes

No

Optional Information
Information in this section is not required to submit your application. To complete the information in this section, enter the following:
1. RACE
American Indian or Alaska Native

Asian

Black or African American

Hispanic/Latino

Native Hawaiian or Other Pacific Islander

White

Female

No response.

2. GENDER
Male

3. HOW DID YOU HEAR ABOUT THE FDA’S TRAINEESHIP PROGRAM?

”I verify that all the information is accurate and truthful.”
SIGNATURE

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