BIRCWH Scholars Program Application
FACE PAGE
The Candidate:
Last Name
First Name
Middle Initial
Birth date
Home address
City
State
Zip
Telephone
Work address
City
State
Zip
Telephone
Email
Fax
Please use the highlight feature to indicate citizenship status and race/ethnicity below
Citizenship:
U.S. Citizen or U.S. Noncitizen National
Permanent Resident of U.S.
Race/Ethnicity:
Are you Hispanic (or Latino)?
Yes
No
Intentionally withheld
What is your racial background? Highlight all that apply
American Indian or Alaska Native
Black or African American
Native Hawaiian or other Pacific Islander
White
Asian
Intentionally withheld
Gender:
Male
Female
Withheld
EDUCATION – AFTER HIGH SCHOOL (Indicate all academic and professional education. For foreign degrees, give U.S. equivalent)
Month/Year Attended
Name of Institution, Department and
Degree(s) Received
(MM/YYYY)
Major Field
Minor Field
Location (List most recent first.)
From
To
Degree
Mo./Yr.
Name of Specialty Boards (if applicable) ___________________________________________
Number of years since residency (if applicable) _________ Years
BIRCWH Scholars Program Application
FACE PAGE
Other Academic Qualifications (Certificates, Diplomas, Awards, etc.)
Institution Name/ Location
Dates of
Type of
Training
Training
Degree/Certificate Earned (if applicable)
Field(s) of Training (Enter up to three)
1)
2)
3)
Previous NIH Support (if applicable)
Name of Grant
Type of Award
PI (Y/N)
Grant Number
Years of Support
Proposed Primary Mentor:
Primary Mentor Name
School
Dept
Division
Dept
Division
Proposed Secondary Mentor:
Secondary Mentor Name
School
Dates of proposed period of support:
Applicant Assurance:
I certify that I have read and understand the Program Requirements and agree to abide by them if I am selected as a
BIRCWH Scholar.
Signature:
Date: