NIH/NCSU MOLECULAR BIOTECHNOLOGY TRAINING PROGRAM (MBTP)
2010 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:
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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 Dr. David
Shafer, Assistant Dean, the Graduate School, Room 209, Research Building III, Campus Box 7102.
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

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NIH/NCSU MOLECULAR BIOTECHNOLOGY TRAINING PROGRAM (MBTP)
2010 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
Date
Analytical
%
Analytical
out of possible __________
__
out of possible __________
3.
Activities, Memberships, Honors, Awards
4.
Publications and Presentations at Professional Conferences
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%
NIH/NCSU MOLECULAR BIOTECHNOLOGY TRAINING PROGRAM (MBTP)
2010 Nomination Form
5.
Statement of Nomination
I,
an
, 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.
B. No individual trainee may receive more than 5 years of aggregate National Research Service
Award support at the predoctoral level, including any combination of support from institutional
training grants and individual fellowship awards.
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:
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Professional Development (B0590B, 2 credits; or equivalent 1 or 2 courses)
Ethics (GN820E, 1 credit; or equivalent 1 credit course)
Capstone Biotechnology Course
C. In accepting this traineeship, I agree to participate in the following events:
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Annual Biotechnology Research Symposium
Service Project
Industrial Rotation
D. I understand that the annual stipend for the MBTP Traineeship stipend is $20,976.
Signed
Date
Applicant
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