Application: OVPR-XXXXXXX Your Name - youremail@email.com Postdoctoral Fellowships for Academic Diversity Summary ID: OVPR-XXXXXXX Status: In Progress Postdoctoral Fellowships for Academic Diversity Application Postdoctoral Fellowships for Academic Diversity at University of Pennsylvania and Children s Hospital of Philadelphia PERSONAL INFORMATION Name M.I. Address/Contact Address 1 * Address 2 City * State * Country * Postdoctoral Fellowships for Academic Diversity Application Form Incomplete Zip Code * Phone Number * Email Address * 1 / 6
Date of Birth * (MM/DD/YYYY) Gender * Citizenship * Ethnicity * Ethnicity Description: Hispanic (or Latino) A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. This does not include persons of Portuguese descent or persons from Central or South America who are not of Spanish origin or culture. American Indian or Alaskan Native A person with origins in any of the original peoples of North America who maintains cultural identification through tribal affiliation or has community recognition as an American Indian or Alaskan Native. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or other Pacific Islander A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Black (or African American) An individual, not of Hispanic origin, with origins in any of the black racial groups of Africa. White (or Caucasian) An individual not of Hispanic origin, with origins in any of the original peoples of Europe, North Africa, or the Middle East. EDUCATION 2 / 6
Check all that apply and list dates for each degree * If you are completing your degree in the coming year, please include the expected date of completion Not Applicable? Date (MM/YYYY) Ph.D D. Phil Psy.D M.D. D.V.M. D.D.S. Other degree(s) not listed above: Degree Type Other #1 Other #2 Thesis Research Advisor * Year (YYYY) * Subject(s)/Specialty * Location * Thesis Title * Residency Training (if applicable) Institution Location Year From (YYYY) Year To (YYYY) Date (MM/YYYY) PRIOR POSTDOTORAL RESEARCH EXPERIENCE ( if applicable) 3 / 6
Number of years of postdoctoral training completed? Number of previous postdoctoral positions held? Last Institution Last Department Dates of most recent postdoctoral position (MM/DD) Date From: Date To: PRIOR TEACHING EXPERIENCE (if applicable) Position #1 Position(s) Held Institution/Location Course Title(s) & Number(s) Date From (MM/YYYY) Date To (MM/YYYY) How many more teaching positions will you be inputting? Input a number between 0 & 4 RECRUITMENT How did you hear about the Postdoctoral Fellowships for Academic Diversity? No Responses Selected 4 / 6
MENTOR Applicants are required to have a Penn and/or CHOP faculty member with compatible research interests submit a letter confirming that he/she is willing to serve as the applicant s primary mentor during the fellowship period. Prior to submitting your application, you should alert your Penn/CHOP mentor that they will receive an email request for their mentor letter. The email will come from: noreply@smapply.io Subject: "YOUR NAME Fellowship Support Letter for Penn/CHOP" Mentors should be familiar with the program guidelines and responsibilities of mentoring. It is recommended that letters include expectations for scholarly work to be completed and a timeline for implementation of the Fellow's research. Mentor Details School * I confirm that I have obtained the agreement of the primary mentor to supervise my research. * REFERENCES Applicants are required to have 3 reference letters submitted on his/her behalf, including one from the applicant's thesis advisor. Prior to submitting your application, you should alert your references that they will receive an email request for their reference letter. The email will come from: noreply@smapply.io Subject: "YOUR NAME Fellowship Support Letter for Penn/CHOP." 5 / 6
Reference #1 (Thesis Advisor) Reference #2: Reference #3: 6 / 6