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VZV Research Foundation

APPLICATION FOR POST-DOCTORAL RESEARCH FELLOWSHIP

 
Date:

Applicant's Information
Name of Applicant and Degrees:
Social Security Number:
Position/Title:
Institution:
Department:
Address:

Telephone Number:
Fax Number:
E-mail:

Mentor's Information

Name of Mentor and Degrees:
Social Security Number:
Position/Title:
Institution:
Department:
Address:

Telephone Number:
Fax Number:
E-mail:

Background on Proposed Study

Requested Period of Performance:
Performance Site:
Are there Human Subjects:(Yes/No)
If "Yes", state IRB Status
Are there Animal Subjects:(Yes/No)
If "Yes", state animal committee status
Are there Biohazards:(Yes/No)
Is the DHHS 596 enclosed: (Yes/No)

Institutional Information

Financial Official of Institution:
Title:
Address:

Telephone Number:
Fax Number:
E-mail:

Send Payments to:
Name of Financial Officer:
Title:
Address:

Telephone Number:
Fax Number:
E-mail:

Application Instructions

Pages 1 and 2: Type or neatly print information requested on pages 1 and 2 of this application.

Pages 4 and 5: Background on Proposed Study (two pages)

Page 6: Specific Aim of Proposed Study (one page)

Pages 7-11: Description of Research (five pages)

Additional, Required Information:

  • Other sources of funding for proposed research, if any;
  • Supporting letter from Mentor, including qualifications of candidate, commitment to candidate, and description of facilities;
  • Additional support of Mentor; and,
  • References.
Filing Deadline: January 24, 2001
Notification to Fellows:March 9, 2001
Commencement of Funding and Study:July 2, 2001

Please forward application (original and four copies) to:

Fellowship Committee
VZV Research Foundation
40 East 72nd Street
New York, NY 10021