INNOVATION FOR CANCER
PREVENTION RESEARCH
http://www.sph.uth.tmc.edu/cpritfellowships/
POSTDOCTORAL FELLOWSHIP APPLICATION FORM: PART 1
REVISED 2012 OCTOBER
THIS IS A WORD TABLE; USE TAB TO GO FROM ONE BLANK TO THE NEXT
PLEASE NOTE: Our funder, the Cancer Prevention and Research Institute of Texas, allows fellows to
be U.S. citizens or noncitizen nationals who hold student visas. All trainees must reside in Texas during
the fellowship. All trainees should be officially enrolled in a collaborating UTHealth school: School of
Public Health, School of Biomedical Informatics, or Graduate School of Biomedical Sciences.
Name:
last or family name
Current
Address:
Permanent
Address:
home:
Phone:
E-mail 1:
first
middle
office:
name you go by
cell:
E-mail 2:
Are you applying to be: Full-time post-doc
Affiliate post-doc
Month, year you wish to begin:
NOTE: This is Part 1 of a 2-part process. Part 1 is used for a preliminary screening of applicants.
Part 2, interviews, is by invitation.
Applicant’s checklist for required application materials, Part 1:
Please submit electronically to CPRITFellowships@uth.tmc.edu:
This application form with checklist completed; label file: Last-First-App-PostDoc.doc
Essays (see p. 3 for content); label file: Last-First-Essays.doc
Curriculum vitae, with name in top corner of each continuation page; label file: Last-First-CV-YYYY-MM-DD.doc
Two first-authored academic writing samples, one from the dissertation; label files: Last-First-Writing1.doc
*Official transcripts from all academic institutions, including UTHealth institutions (list them on p. 2)
If you have attended UTSPH, please request that comment cards be sent with your transcript.
*Graduate Record Examination scores (or comparable graduate exam)
Note: if these are no longer available, please send a photocopy of your original score report.
*3 letters of reference, at least 2 academic, including 1 from your dissertation supervisor, each signed and on letterhead;
Send in a sealed envelope or as a .pdf CPRITFellowships@uth.tmc.edu (list them on p. 2)
A signed copy of this application (signature on p. 3)
* If you applied to UTSPH via SOPHAS, e-mail Tiaresa.E.Carter@uth.tmc.edu to request that she release your entire file
to CPRITFellowships@uth.tmc.edu. You do not need to provide duplicate information for * items.
Other schools can also release your transcripts, etc. to CPRITFellowships@uth.tmc.edu
p. 2
Name:
List all colleges and universities attended, beginning with the current/most recent institution.
Full name of
institution, location
Dates
attended
(month/year)
Major field
of study
Degree
Date awarded or expected
(month/year)
Date
transcript
requested
*
* See note on p. 1 about transcripts on file with a collaborating school.
List other training experience, beginning with the current/most recent institution.
Full name of
institution, location
Dates attended
(month/year)
GREs or other exams
Date taken
Type of experience (e.g., residency)
Verbal
Quant.
Area of specialty
Analyt.
Supervisor
Date scores
requested
*
* See note on p. 1 about scores on file with a collaborating school.
List letters of reference requested. (Provide name, degree, title, institution, telephone numbers, and e-mail addresses.)
Each letter should be on letterhead and signed; send in a sealed envelope or as a .pdf to
CPRITFellowships@uth.tmc.edu. See note on p. 1 about letters on file with a collaborating school.
1. Dissertation supervisor or equivalent.
If your dissertation is not yet complete, your supervisor should provide a progress report and estimated date
for completing all degree requirements.
Name, degree:
Title, institution:
Telephone:
E-mail:
2. Other academic reference.
Name, degree:
Title, institution:
Telephone:
E-mail:
3. Third reference.
Name, degree:
Title, institution:
Telephone:
E-mail:
p. 3
Name:
Essays
In a separate electronic document, please address the following questions:
1. What are your long-term career goals? (250 words)
2. What is your most important achievement in the past 5 years? (It doesn’t need to be in the academic
realm.) Why do you value it, and what do you think it tells us about you? (250 words)
3. What skills, knowledge, and experiences would you bring to the fellowship? (250 words)
If any information relevant to this application is under a different name, please list those name(s):
Country of citizenship:
If you are not a U.S. citizen, are you classified by ICE as a
“permanent resident” or “alien resident” of the United States?
Yes:
If you are not a U.S. citizen or resident, do you hold a student visa?
Have you ever been convicted of a felony?
If yes, please give details including dates:
Yes:
No:
Yes:
No:
No:
The following information is used for our statistical reports to the funding agency:
Race/Ethnicity:
U.S. Veteran:
Date of Birth (YYYY/MM/DD):
Male:
Female:
Please read the following statement carefully before signing:
I understand that all application materials become the property of the institution and will not be returned. I also understand that the institution is not obligated to furnish me with duplicate copies. I understand that the information submitted herein will be relied upon by the Innovation for Cancer Prevention Research training program to determine my eligibility for appointment and training. I authorize
the institution to verify the information I have provided. I understand that any evaluations or verifications made with respect to this application are confidential and will not be disclosed to me. I certify
that the information in the application is complete and correct to the best of my knowledge and belief.
I acknowledge that the submission of any false information is grounds for rejection of my application,
withdrawal of any acceptance offer, appointment revocation, or appropriate disciplinary action after
appointment.
Signature:___________________________________________________Date:________________________