THE FOUNDATION FOR PSYCHOCULTURAL
RESEARCH
POSTDOCTORAL FELLOWSHIP
IN INTERDISCIPLINARY STUDIES OF CULTURE AND NEUROSCIENCE
Application for the CBDMH project, Culture and Autism: India and the U.S.
APPLICATION COVER SHEET
Requested support activation date:
________________
(List earliest possible date you can start) Month/Day/Year
APPLICANT’S NAME :
_____ ________________________________
Title First name
_____
DOCTORAL DEGREE(S) AND DATE(S) RECEIVED :
Requested duration of support:_____________
Number of years
___________________________________
M.I.
Last name
_________________
Degree
___________________
Date received (M/D/Y)
_________________
Degree
___________________
Date received (M/D/Y)
TITLE OF THE PROPOSED RESEARCH PROJECT :
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PRIMARY SPONSOR’S NAME : ____ Thomas S. Weisner __________________________________________
INSTITUTION :
_____UCLA___________________________________________________
_____________________________________________________________
SECONDARY SPONSOR’S NAME : ___________________________________________________________
INSTITUTION :
____ UCLA ____________________________________________________
_____________________________________________________________
LETTERS OF RECOMMENDATION FROM :
1
_____________________________________
Name
________________________________________
Institution
________________________________________
2
_____________________________________
Name
________________________________________
Institution
________________________________________
Application form
The Foundation for Psychocultural Research postdoctoral fellowship in
INTERDISCIPLINARY STUDIES OF CULTURE AND NEUROSCIENCE
Application for CBDMH project, Culture and Autism: India and the U.S.
SECTION ONE
PROJECT INFORMATION
PROJECT TITLE :
[This section is for applicant’s own project information, not for the core project, Culture and Autism: India and the U.S.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
RESEARCH SITE/S:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SPONSORING INSTITUTIONS AT UCLA:
______________________________________________________________________________
Primary Institution
______________________________________________________________________________
______________________________________________________________________________
Primary Sponsor’s name:
______________________________________________________________________________
Project: _____________________________________________________________________________________________
______________________________________________________________________________
Secondary Institution
______________________________________________________________________________
______________________________________________________________________________
Secondary Sponsor’s name:
______________________________________________________________________________
Project: _____________________________________________________________________________________________
Application form
The Foundation for Psychocultural Research postdoctoral fellowship in
INTERDISCIPLINARY STUDIES OF CULTURE AND NEUROSCIENCE
Application for CBDMH project, Culture and Autism: India and the U.S.
SECTION TWO
INSTITUTIONAL CERTIFICATIONS
SPONSORING INSTITUTION PLEASE COMPLETE THE FOLLOWING:
THE PROPOSAL INVOLVES:
A. HUMAN SUBJECTS:
If yes: Exemption No. or Assurance of Compliance No. ___________________________
B. VERTEBRATE ANIMALS :
If yes: Animal Welfare Assurance No. ____________________________
C. RECOMBINANT DNA AND/OR OTHER NONEXEMPT BIOHAZARDS:
If yes: Assurance Compliance No. ___________________________
______________________________________ _________________________________
Name and Title or IRB or Certifying Officer
Signature of IRB or Certifying Officer
PLEASE NOTE: signature required even if none of the items apply.
INSTITUTIONAL CERTIFICATION AND APPROVAL:
___________________________________________
(Name of Sponsoring Institution)
HEREBY CERTIFIES THAT:
__________________________________________
(Fellowship Applicant’s Name)
____________________________________________
(Name of Sponsoring Institution)
holds/will hold the position of:
__________________________________________
____________________________________________
at these institutions, and that the research described within this application will be conducted under the supervision of:
__________________________________________
____________________________________________
(Primary Sponsor’s name)
(Secondary Sponsor’s name)
of these institutions, and that this application for a postdoctoral fellowship has been reviewed and approved by
the following institutions:
____________________________________________
Administrative Officer’s Signature
____________________________________________
Administrative Officer’s Signature
____________________________________________
Name
____________________________________________
Name
____________________________________________
Title
____________________________________________
Title
____________________________________________
Address
____________________________________________
____________________________________________
Address
____________________________________________
____________________________________________
____________________________________________
____________________________________________
City, State, Zip
____________________________________________
City, State, Zip
_______________________ ____________________
Tel.
FAX
_________________________
E-mail
Application form
_______________________ __________________
Tel.
FAX
____________ ____________________________
Date
E-mail
__________
Date
The Foundation for Psychocultural Research postdoctoral fellowship in
INTERDISCIPLINARY STUDIES OF CULTURE AND NEUROSCIENCE
Application for CBDMH project, Culture and Autism: India and the U.S.
SECTION THREE
SPONSORS’ INFORMATION
Primary sponsor will be Thomas S. Weisner. For secondary sponsor, complete the information below:
SECONDARY SPONSOR:
______________ ______ __________________________
First name
M.I.
Last name
Doctoral Degree(s): _______________ ________________
Title/s: _________________________________________
_______________________________________________
Mailing Address:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
__________________
Tel.
____________________
FAX
_______________________________________________
E-mail address
_______________________________________________
Website
INTERDISCIPLINARY RESEARCH/ INTERESTS:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Signature:
____________________________________________
Date:
______________________________
Month/Day/Year
Application form
The Foundation for Psychocultural Research postdoctoral fellowship in
INTERDISCIPLINARY STUDIES OF CULTURE AND NEUROSCIENCE
Application for CBDMH project, Culture and Autism: India and the U.S.
SECTION FOUR
APPLICANT’S INFORMATION
_______ __________________________________
Title
First name
Doctoral degree(s) ___________________
_______ _________________________________
M.I.
Last name
___________________
Mailing address: ______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_____________________
Tel.
Sex: ____________
Female / Male
_____________________
FAX
Date of Birth: _________________
Month/Day/Year
___________________________________
E-mail
____________________________
Social Security No.
Place of Birth: ________________________________________________________________________________
City
State
Country
Most recent Doctoral degree: _________________ Date received: ___________________
Month/Year
If pending, expected date of completion:____________________
Month/Year
Degree-granting Institution: _______________________________________________________________________
_____________________________
City
________________________________________
State, Country
Other Doctoral degree(s): _________________________
Date received: ____________________
Month/Year
Degree-granting Institution ________________________________________________________________________
Other Graduate degree(s):
_____________________________
City
_________________________________________
State, Country
______________________________
Date received: ____________________
Month/Year
Degree-granting Institution ________________________________________________________________________
_____________________________
City
Undergraduate degree(s):
_____________________________
_________________________________________
State, Country
Date received: ____________________
Month/Year
Degree-granting Institution ________________________________________________________________________
_____________________________
City
_________________________________________
State, Country
Letters of Recommendation from: 1. ____________________________________________________
2. ____________________________________________________
Application form