Application for Keystone Symposia Fellows Program
This program is funded in part by the NIH; therefore, those employed by the National
Institutes of Health are not eligible to apply.
This program requires participation in on-line study groups, on-site participation at both January and
June Scientific Advisory Board meetings in Keystone, Colorado, and regular communication with
scientists, Keystone Symposia Fellows and Program staff throughout the Program. By submitting this
application you are committing to participate in all of these activities. Please review the list of
requirements prior to submission of your application.
Completed application forms and all required supporting documents must be received by (or be
postmarked no later than) 12PM (Mountain Time) on September 30, 2015. Place your full name on all
pages of the application and supporting documents.
I hereby certify that information and documentation included in this application and supporting
documents is true.
Signature __________________________________________ Date (m/d/y) _____________________
Last Name _________________________________
First Name _____________________________
Middle Name _______________________________
Residential Address
Street _______________________________________________
City ________________________________________
Apt/Unit # _________________
State ________ Zip Code ________________
Cell Phone Number
(_______)-_______________________
Home Land Line
(_______)-_______________________
Email address ________________________________________________________________________
Date of Birth (m/d/y) _____________________________________
☐ Male
☐ Female
☐ U.S. Citizen
☐ Permanent Resident
☐ Non-US Resident
I hereby certify that I am a U.S. Citizen or Permanent Resident of the United States.
Signature _________________________________________
Date (m/d/y) _____________________
Ethnic Identity (check one)
☐ Black/African American
☐ Hispanic/Latino
☐ American Indian/Alaska Native
☐ Native Hawaiian/Other Pacific Islander
OR
☐ Disability:
______________________________________________________________________________
Current Employer
Name ______________________________________________________________________________
Position Title _________________________________________________________________________
Start Date _____________________________________
Department __________________________________________________________________________
Street ______________________________________________ Suite Number ____________________
Mail Drop ___________________________________________
City ________________________________________________ State ________ Zip Code ___________
Your Laboratory Supervisor/Head/Department Chair
Name ______________________________________________________________________________
Email address ________________________________________________________________________
Institution ___________________________________________________________________________
Address _____________________________________________________________________________
City ________________________________________
State ________ Zip Code ________________
Office Telephone (_______)-________________________ Extension ____________________
If you are currently in a training program, indicate the following:
Name of Training Program
____________________________________________________________________________________
Agency/Organization/Company/University
____________________________________________________________________________________
Address
____________________________________________________________________________________
____________________________________________________________________________________
Your Title ___________________________________________________________________________
Time in this program and start date for this program __________________________________________
Email _______________________________________________________________________________
Program Office Telephone (_______)-________________________ Extension ____________________
Graduate Education (Doctorate)
Institution ___________________________________________________________________________
Address _____________________________________________________________________________
City ________________________________________
State ________ Zip Code ________________
Degree _____________________________________
Year Received __________
Additional Degrees (Master’s, etc.)
Institution ___________________________________________________________________________
Address _____________________________________________________________________________
City ________________________________________
State ________ Zip Code ________________
Degree _____________________________________
Year Received __________
What is your research area? (please select one)
☐ Biochemistry
☐ Immunology
☐ Biophysics
☐ Infectious Diseases
☐ Cancer
☐ Metabolic Diseases
☐ Cardiovascular
☐ Molecular Biology
☐ Cell Biology
☐ Neurobiology
☐ Development
☐ Plant Biology
☐ Drug Discovery
☐ Structural Biology
☐ Genetics/Genomics
☐ Technologies
How did you find out about this program (colleague, P.I., Department Chair, Keystone Symposia website, internet,
email message, etc.)?
____________________________________________________________________________________
Are you currently an Endocrine Society Flare Fellow?
☐ Yes
Have you ever attended a Keystone Symposia research conference?
☐ No
☐ Yes
☐ No
Did you see advertisements about the Fellows Program in any of the following organizational publications?
(Please check all that apply)
☐ ABRCMS Conference Program, email announcements
☐ SACNAS Newsletter, journal, conference program
☐ Other (please specify): ___________________________________________________________