Application for Keystone Symposia
Early Career Investigator Travel Award (ECITA)
Eligibility Requirements – Applicant must meet ALL of the following eligibility requirements:
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Applicant must be a United States citizen or Permanent Resident.
Applicant must be a member of a federally designated underrepresented (UR) population, which
includes African American, Hispanic/Latino, American Indian/Alaskan Native, Hawaiian
Native/ Pacific Islander
Applicant must be an assistant professor or equivalent scientist in industry, be no greater than
four (4) years into appointment, and engaged in full-time laboratory research.
In addition to the above requirements, applicants are asked to consider mentoring a student or postdoc from
a UR population for a one (1) year period beginning after attendance of the research meeting of interest. This
student should not be one already currently being mentored and should not be scheduled to graduate prior
to the year of the applicant’s potential mentoring period.
I hereby certify that information and documentation included in this application is true
and correct.
Signature __________________________________________________________________
Date ____________________________________
(Please print)
First Name _________________________________________________________________
Middle Name _______________________________________________________________
Last Name _________________________________________________________________
Date of Birth (month/day/year) ________________________________________________
Gender: _____ Male _____ Female
Ethnic Identity (check one):
_____ African American/Black
_____ Hispanic/Latino
_____ Native American/Alaskan Native
_____ Pacific Islander/Native Hawaiian
Citizenship (please check one):
_____ United States Citizen
_____ Permanent Resident
Home Address
Street _____________________________________________
City ___________________________________
Apt/Unit # _______________
State ________ Zip Code _____________
Telephone
Cell:
(_____) ______ - _____________
Office (_____) ______ - _____________
Email Address
Work ______________________________________________________________________
Alternate ____________________________________________________________________
Employment Information
Institution Name _______________________________________________________________
Department __________________________________________________________________
Street _______________________________________________________________________
Suite/Mail Drop # ______________________________________
City ___________________________________
State ________ Zip Code _____________
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Position Title _________________________________________________________________
Start date for this position _______________________________________________________
If you are currently in a training program:
Name of Training Program ______________________________________________________
Agency/Organization/University __________________________________________________
City ___________________________________
State ________ Zip Code _____________
Your Title ____________________________________________________________________
Start Date and Length of Time in Program __________________________________________
Program Office Telephone (_______) ______ - ______________
Education Information
Undergraduate
Institution ____________________________________________________________________
City ___________________________________
State ________ Zip Code _____________
Degree Earned: _________________________ Year Received ________________________
Graduate (Doctorate)
Institution ____________________________________________________________________
City ___________________________________
State ________ Zip Code _____________
Degree Earned: _________________________ Year Received ________________________
Where did you complete your postdoctoral training?
____________________________________________________________________________
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Date completed _______________________
Additional Education (Master’s, etc.)
Institution ____________________________________________________________________
City ___________________________________
State ________ Zip Code _____________
Degree Earned: _________________________ Year Received ________________________
Do you have your own laboratory?
_____ Yes
_____ No
If yes:
Laboratory Name ______________________________________________________________
Email Address ________________________________________________________________
Institution/Organization _________________________________________________________
City ___________________________________
State ________ Zip Code _____________
Telephone (_______) ______ - ______________
How many of the following do you currently have employed in your lab (indicate number of
each):
_____ Postbac
_____ Graduate Student
_____ Postdoc
_____ Assistant Professor
_____ Research Scientist
_____ Undergraduate
Specific Research Area:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If awarded the Early Career Investigator Travel Award, what Keystone Symposia conference
would you attend?
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Conference Title
____________________________________________________________________________
____________________________________________________________________________
Conference Dates _____________________________________________________________
Specifically state how this travel award will benefit your research at present:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What is the specific research question you are attempting to answer? (please be specific and
state an actual question)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Have you ever attended a Keystone Symposia research conference?
_____ Yes
_____ No
How did you hear about the Keystone Symposia Early Career Investigator Travel Award?
_____ Colleague (please indicate name of colleague)
______________________________________________________________________
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_____Prior ECITA awardee (please indicate name)
_______________________________________________________
_____ Keystone Symposia website
_____Professional meeting, including SACNAS, ABRCMS, or society meeting
_____ Received email information
_____ Other (please indicate)
______________________________________________________________________
Part of the philosophy behind this award program is that we wish to provide a mechanism by
which to help address the national workforce capacity needed to increase participation in life
and biomedical research by scientists from historically underrepresented backgrounds. Further,
it is the goal of this initiative to impact the number of scientists progressing up the ladder to
tenured academic appointments. If you are the recipient of this award, Keystone Symposia
asks you to consider mentoring a student or postdoc in your laboratory from an
underrepresented minority background for a period of one (1) year commencing with the end of
the research meeting you will potentially attend. The knowledge transfer of ECITA awardees
with more junior scientific talent will greatly contribute to the development of next-generation
scientists.
_____ I agree to mentor a student from a federally designated UR population in my
laboratory.
_____ I cannot agree at this time to mentor a student from a federally designated UR
population in my laboratory.
Signature ____________________________________________________________________
Date ___________________________
Please email this form and your research abstract (relevant to the proposed Keystone Symposia
meeting you would like to attend) to the Director of the Diversity in Life Science Programs
(DLSP), Dr. Irelene Ricks, between November 2-30 for Keystone Symposia meetings starting in
February 2016. For meetings starting later in the year, please check our website
http://www.keystonesymposia.org/meetings for the schedule. If you have questions, please
contact Dr. Ricks at irelener@keystonesymposia.org or (970) 262-2669. DO NOT submit your
abstracts using the links on the Keystone Symposia website. All abstracts must be
emailed to Dr. Ricks with your application.
Revised IPR/10/21/15
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