APPLICATION FOR ADMISSION
The University of Michigan Substance Abuse Research Center
National Institute on Drug Abuse (NIDA)
Interdisciplinary Research Training Grant in Substance Abuse
 Pre-doctoral position
Applying for
 Post-doctoral position
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK
1.
US Social Security Number
2.
Full Name
Last/Family Name
3.
Permanent Address
valid until
First
Middle
4. Mailing Address (if different) valid until
Street, Apt. #
Street, Apt. #
City, State, Country, Mail/Zip Code
City, State, Country, Mail/Zip Code
Daytime Phone
Electronic mail address
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5.
Female
6.
US. Citizen
7.
Birth Date
Male
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Daytime Phone
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 Permanent Resident Alien - Reg. No. ABirthplace
Month/Date/Year
8.
Please list other names that may appear on
transcripts, documents, test results
City, State/Country
Michigan Resident since
Not a Michigan Resident
Month/Year
9.
Civil Rights Code (optional). Used to assess the progress of Affirmative Action at U M (check one).
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10.
1.
2.
3.
4.
5.
6.
7.
Black/African American
Asian American
Native American
Puerto Rican/Mexican American (please specify)
Other Hispanic/Latino (a) (please specify)
White/Non-Hispanic
I do not wish to designate a code.
If your native language is NOT English, you will need to take either the TOEFL or the MELAB. Indicate
the test you have taken, or plan to take, and your score.
TOEFL: month/year of test
MELAB: month/year of test
Ap for Admit
Test Score and Registration Number, if known
Test Score and ID Number, if known
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11.
List all institutions where you received or will receive a degree. In addition, list all other post-secondary
institutions attended. Submit one official transcript from each institution. Post-doctoral applicants must
have completed a degree within the past 8 years and should include evidence of completion of
doctoral work if it does not appear on your transcript.
Institution
12.
City, State/Country
From
Through
Major
Degree/Diploma
Date received/expected
Pre-doctoral applicants must reasonably expect to have completed all preliminary exams by July 1, 2005.
(see doctoral advisor form):
Name of program
Date of preliminary exams
Candidate Status? ___ Yes ___ No
Doctoral Advisor/Committee Chair
Advisor’s Address/Phone/e-mail
13.
Post Doctoral applicants must have a reasonable expectation of defending their dissertation by July 1,
2005. Post doctoral fellows cannot be appointed until they provide a statement from their institution
indicating that defense and other requirements for the doctoral degree have been satisfactorily completed.
Evidence of date or expected date of defense (if it will not appear on the official transcript) must be
included.
14.
Indicate funding sources, institutions, advisors and dates for any pre or postdoctoral training positions to
date:
Funding Source
15.
Institution
Supervisor
Dates
Give titles of publications or major papers in which you are the author or co-author. If published, give
compete citation. You are encouraged to attach reprints or abstracts.
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16.
List the major scholarships and/or fellowships you have held as a graduate and an undergraduate student.
Award Title
Dates/Academic Year
Institutions
17.
List major academic recognition, honors, and memberships including honor societies.
18.
List employment/other relevant activities not already reported.
Position
19.
Institution/Employer
Nature of Work
Dates
Individuals asked to provide letters of recommendation. Recommendations should come from individuals
other than mentors listed below. (Please allow adequate time for letters to be received at UMSARC by July
1, 2005). **Applications will not be considered without these letters.
Name
Institution
1.
2.
3.
20.
Name of at least two University of Michigan faculty who have been tentatively identified to serve as
mentors. A pre-doctoral applicant identifies two mentors, one mentor from our NIDA Core Faculty and
the other from the degree granting/home department who will serve as the dissertation chair. A postdoctoral applicant identifies two UMSARC faculty mentors from different disciplines; one mentor - their
primary mentor - is part of our NIDA Core Faculty working in areas related to the trainee’s interests and/or
disciplines. The primary mentor assumes the majority of mentorship responsibilities. It is preferred that the
second mentor be selected from our NIDA Secondary Faculty, but can be selected from the UMSARC
Membership list. (See NIDA Faculty & UMSARC Membership lists).
Name
Department
1.
2.
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3.
21.
The training grant requires full-time participation and commitment. Please list other financial support from
awards, appointments or grants applied for or expected during the period of this fellowship. Comment on
the nature of your commitment as a result of these awards, appointments or grants (i.e., will you be expected
to teach, to conduct research, or other activities)?
22.
Other information not listed on this form, which you feel would strengthen your application.
23.
I certify that I have read all of the instructions and that I have answered all of the questions completely and
truthfully. I understand that misrepresentation of any portion of this application, including supporting
credentials and documents, may be cause for canceling my financial award and appointment. I also
understand that all credentials and documents that I submit become the property of the University of
Michigan.
Signature ________________________________________________
Date
________________________________________________
Telephone number(s) where you can be reached: _________________________
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