APPLICATION FORM FOR
POSTDOCTORAL FELLOWSHIPS FOR ACADEMIC DIVERSITY AT THE
UNIVERSITY OF PENNSYLVANIA
Please fill out the following information by placing a check in the appropriate boxes and filling in the blanks.
All applications should be submitted electronically to pdfellow@exchange.upenn.edu. Subject line should be
applicant’s name.
1. PERSONAL INFORMATION:
First Name:
Address:
City, State, and Zip:
Phone number:
MI:
Email address:
Social Security #: XXX-XXU.S. Citizen
Last Name:
Date of Birth:
- -
Gender:
Female
Male
Transgender
U.S. Permanent Resident
Note: The category that most closely reflects the individual’s recognition in the community should be used
when reporting mixed racial and/or ethnic origin.
American Indian or Alaskan Native. A person having origins in any of the original peoples of North
America, and who maintains a cultural identification through tribal affiliation or community recognition.
Asian or Pacific Islander. A person having origins in any of the original peoples of the Far East, Southeast
Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan,
Korea, the Philippine Islands, and Samoa.
Black, not of Hispanic origin. A person having origins in any of the black racial groups of Africa.
Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture
or origin, regardless of race.
White, not of Hispanic origin. A person having origins in any of the original peoples of Europe, North
Africa, or the Middle East.
2. EDUCATION:
Please check all that apply and list dates for each degree.
M.D.
D.V.M.
D.D.S.
Ph.D.
-
Other
Thesis Title:
Thesis Research Advisor:
Year:
Subject(s)/Specialty:
egree(
University(s):
Country:
s)
award
If
completing a residency, residency training institution:
ed:
Postgraduate
year:
D.Phil.
-
-
APPLICATION FORM FOR
POSTDOCTORAL FELLOWSHIPS FOR ACADEMIC DIVERSITY AT THE
UNIVERSITY OF PENNSYLVANIA
3. PRIOR POSTDOCTORAL EXPERIENCE:
How many years of postdoctoral training have you completed?
Yrs.
How many previous postdoctoral positions have you held?
Last Department:
Last Institution:
4. PRIOR TEACHING EXPERIENCE:
Institution(s)
Position(s) held
Course Title & Number(s)
Dates
. .
to
.
.
.
.
to
.
.
.
.
to
.
.
5. RECRUITMENT:
How did you hear about Postdoctoral Fellowships for Academic Diversity?
The Almanac
BPP Website
Advertisement (Journal Title:
)
Recommended by mentor
Word-of-mouth
Other
Please identify three potential research mentors at Penn and the school in which you wish to study. This will
help in the identification of potential research laboratories. Please also indicate if you have discussed the
potential position with the mentor listed.
Mentor Name
Mentor professional email
Penn Mentor
Contacted (Y/N)
School
Please list the three individuals who will submit letters of reference on your behalf:
Name
Email
Institution
APPLICATION FORM FOR
POSTDOCTORAL FELLOWSHIPS FOR ACADEMIC DIVERSITY AT THE
UNIVERSITY OF PENNSYLVANIA
6. ADDITIONAL MATERIALS:
1) A curriculum vitae including current and pending publications
2) A personal statement, no longer than three pages, which addresses the following:
 reviews your previous research accomplishments
 outlines your future research goals and proposed research
 describes your commitment to pursuing an academic career
 and includes academic, employment or other life experiences that would bring new perspectives
to the University community and your chosen field
3) Three letters of reference from people acquainted with the applicant’s work. One reference
letter should be from the applicant's thesis advisor or faculty mentor. Reference letters must be
submitted electronically on letterhead stationery in PDF format. Email subject line should be
applicant's name followed by the words reference letter, e.g. Jane Smith_ Reference letter.
4) In addition, applicants are encouraged to a submit a letter from a Penn faculty member having
similar research interests confirming that he/she is willing to serve as the applicant’s primary
mentor during the fellowship period. This letter should be submitted with the application
materials.
Incomplete submissions will not be reviewed.
If you have any questions please contact Josie Rook, Executive Director, Office of the Vice Provost for
Research at pdfellow@exchange.upenn.edu.
Revised May 2012