26th Annual Trainee Research Symposium
Medical Students, Residents, & Fellows—Thursday, April 28, 2016
Graduate Students—Friday, April 29, 2016
South Auditorium, Springfield Campus
ABSTRACTS DUE MONDAY, MARCH 7, 2016 BY 4 P.M.
Application Form
Fill in the blue boxes with the information requested or mark an X.
Name:
First Name Last Name:
Title of Project (only one submission per trainee can be submitted):
Status:
Medical Student:
Resident:
Ph.D. Student: Yes
Year:
Masters Student:
Department:
Email Address (please list the email address you check on a daily basis and the most frequently):
Home Address:
Street Address:
City/State/Zip:
Phone Number:
Home or Cell Phone:
Lab Phone:
Name of Primary Mentor:
Primary Mentor’s Name:
Department:
Has primary mentor approved the version of the abstract that is being submitted?
Yes
No
Primary Mentor’s Phone Numbers:
Office Phone:
Lab Phone:
Authors (list all):
Name:
Department:
Pharmacology
For graduate students only:
Preferred Type of Presentation:
Oral Presentation
Yes
OR
NO PREFERENCE
No
OR
Poster Presentation
(maximum of 15 posters)
Yes
No