NIH/NCSU MOLECULAR BIOTECHNOLOGY TRAINING PROGRAM (MBTP) 2013 Nomination Form To nominate a graduate student for a NIH/NCSU Molecular Biotechnology Training Program (MBTP) Traineeship, please complete this form and attach the following supporting documentation: Copies of student’s undergraduate and graduate transcripts; Copy of student’s GRE results; Letter of recommendation from faculty advisor (biotechnology training faculty member); Statement of intent from student (including research & biotechnology interests); and Plan for industrial rotation This nomination form and supporting documentation should be completed and returned to Todd Marcks, the Graduate School, Room 215, Research Building III, Campus Box 7102 – email: todd_marcks@ncsu.edu. Please print or type all information 1. Personal Data Name of Nominee:____________________________________________________________ Last First Middle Student ID Number: __________________ Date of Birth: Place of Birth: ______________________________ (mm/dd/yy) City/Town Mailing Address: ___________________________________________________________ Street/Box ____________________________________________________________ City/Town State Home Telephone: Zip Office Phone: E-Mail Address: _________________________________________ Department: ____________________________________________ MBTP Faculty Advisor: _________________________________________ Advisor's E-Mail Address: _________________________________________ Present Status: U.S. Citizen Permanent Resident of the United States Gender: Female Male Ethnicity: African American Alaskan Native/Pacific Islander American Indian Asian Hispanic White 1 of 3 NIH/NCSU MOLECULAR BIOTECHNOLOGY TRAINING PROGRAM (MBTP) 2013 Nomination Form 2. Education Name of School/ Location Attendance From GRE Scores: Verbal GRE Percentiles: Verbal To Degree Received Degree Quantitative % Quantitative Undergraduate Cumulative GPA: _ Graduate Cumulative GPA: Major Analytical Writing _____ % Analytical Writing % out of possible __________ __ out of possible __________ 3. Activities, Memberships, Honors, Awards 4. Publications and Presentations at Professional Conferences 5. Statement of Nomination I, an Date , hereby nominate (MBTP Faculty Advisor) for (Nominee) NIH/NCSU Molecular Biotechnology Training Program Fellowship. I understand and agree to the following fellowship conditions: A. Departments are responsible for providing tuition remission for out-of-state trainees. 2 of 3 NIH/NCSU MOLECULAR BIOTECHNOLOGY TRAINING PROGRAM (MBTP) 2013 Nomination Form B. No individual trainee may receive more than 5 years of aggregate National Research Service Award support at the pre-doctoral level, including any combination of support from institutional training grants and individual fellowship awards. C. As the sponsoring trainer, I agree to participate in MBTP functions, in particular the annual Molecular Biotechnology Symposium. The following signatures must be included: Signed Date MBTP Training Faculty Member Signed Date Department Head or Director of Graduate Programs (Appropriate authorizing official should sign) 6. Statement from Nominee A. Having carefully read the "Fact Sheet" describing the MBTP Program, I am applying for a new MBTP Traineeship. My plans are to remain on this fellowship for two years. B. In accepting this fellowship, I agree to fulfill the following course requirements in addition to the requirements of my graduate program: Professional Development (BIT 815D, or equivalent to be approved by RM Kelly) Research Ethics (BIT 815K, or equivalent to be approved by RM Kelly) Capstone Biotechnology Course (BIT 815N) Graduate Biotechnology minor (BIT 510 and two BIT modules, or 3 BIT modules in place out of BIT 510 – to be approved by RM Kelly) C. In accepting this traineeship, I agree to participate in/complete the following: Annual Biotechnology Research Symposium Service Project Industrial Rotation D. I understand that the annual stipend for the MBTP Traineeship stipend is $22,032. Signed Date _______________ Applicant 3 of 3