Instructions:
The applicant is expected to prepare the complete application, obtain the
letters of recommendation, then submit one complete PDF file containing all
of the materials to Brenda McAreavy at brenda-mcareavy@uiowa.edu.
If the mentor would prefer to keep the letters of recommendation
confidential, then the letters should be submitted to the mentor for
assembling and submission.
Please do not send incomplete applications.
If you have any questions, please call Brenda McAreavy at 319-335-7811.
POSTDOCTORAL RESEARCH FELLOWSHIP APPLICATION
INTERDISCIPLINARY IMMUNOLOGY POSTDOCTORAL TRAINING PROGRAM
College of Medicine
University of Iowa
Iowa City, IA 52242
1.
Applicant Name:
(Last)
2.
Present Address:
3.
Permanent Address:
4.
Phone Numbers:
(First)
Social Security
Number:
(Middle)
(work)
(home)
5.
Date of Birth:
6.
Place of Birth:
7.
U.S. Citizen or U.S. Noncitizen National
_____ Yes
8.
If you are not a citizen of the U.S. or noncitizen national, what is your visa status?
a) F Visa (Student) _____ b) J Visa (Exchange Visitor) _____ c) Permanent Visa _____
_____ No
If permanent visa, indicate number of green card
9.
or proof of status.
For physicians engaged in patient care only: Iowa Medical License Number:
(required)
10.
*ECFMG Number:
Interim:
Standard:
*Please attach copy of certification of Educational Council for Foreign Medical Graduates if you
are a graduate of a medical school outside the U.S. or Canada.
11.
a) Are you applying for concurrent training support from a federal agency?
b) Have you ever received any federal training support? _____ Yes
_____ No
If the answer to (a) or (b) is “yes” describe all grants, scholarships and fellowships in the space
provided on the following page.
12.
Training to begin on:
Name of Sponsor:
Immunology Postdoctoral Training
Program Application - continued
CANDIDATE’S BIOGRAPHICAL SKETCH
Name
Social Security Number
Title
Education (begin with baccalaureate; include postdoctoral training)
Name, location of institution and title of
training program
Degree
Year Awarded
Major Research Interest(s)
Briefly summarize your scientific and/or research experience to date. State results, if any, of this
experience. Do not list academic courses here.
Honors and Awards
Immunology Postdoctoral Training
Program Application - continued
Name:
Last
First
Middle
PERFORMANCE IN GRADUATE AND PROFESSIONAL STUDIES
List below all graduate and/or basic science professional sources with institution and years attended. List
only those courses completed within the past ten years. (A copy of an official graduate or professional
school transcript will substitute for this part.)
Major
Year Descriptive Title
Grade
Year
Descriptive Title
Grade
Explain marking system if other than 1-100 or A, B, C, D, F. Specify level required for passing, honors.
List names of special boards of which you are a diplomate
(or board-eligible) and date certified.
Have you completed a residency
specialty board certification?
yes
no
If in residency, state your progress
and specialty:
Will you be seeking a degree during proposed
Fellowship tenure? _____ yes
_____ no
If “yes”, indicate degree(s) sought:
Date you expect to complete
requirement for degree(s):
(month and year)
Immunology Postdoctoral Training
Program Application - continued
Name:
Last
First
Middle
List the names of two individuals you will request to submit references. If applicable, one of these should
be your Ph.D. Thesis Advisor.
Name
Title and Department
Institutional Address
Describe your research career goals and indicate the relevance of the proposed training to these goals.
Bibliography:
Immunology Postdoctoral Training
Application - continued
Name:
Last
First
Middle
SUMMARY DESCRIPTION OF PROJECT
Principal Investigator
Title of Project
Brief description of research project, including a list of specific aims. (Limit: 1 single-spaced page to
be written by the applicant.)