Postdoc Personal Data Form

APPLICATION FORM FOR POSTDOCTORAL FELLOWSHIPS FOR ACADEMIC DIVERSITY AT THE UNIVERSITY OF PENNSYLVANIA

Please fill out the following information by placing a check in the appropriate boxes and filling in the blanks. All applications should be submitted electronically to [email protected]. Subject line should be applicant’s name.

1. PERSONAL INFORMATION:

First Name: MI: Last Name: Address: City, State, and Zip: Phone number: Email address:

Social Security #: XXX-XX- Date of Birth: -- Gender: Female Male Transgender

U.S. Citizen U.S. Permanent Resident

Note: The category that most closely reflects the individual’s recognition in the community should be used when reporting mixed racial and/or ethnic origin.

American Indian or Alaskan Native. A person having origins in any of the original peoples of North America, and who maintains a cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islander. A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.

Black, not of Hispanic origin. A person having origins in any of the black racial groups of Africa.

Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South America, or other Spanish culture or origin, regardless of race.

White, not of Hispanic origin. A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

2. EDUCATION:

Please check all that apply and list dates for each degree. Ph.D. - D.Phil. - M.D. - D.V.M. - D.D.S. - Other -

Thesis ThesisTitle: Research YeaAdvisor: Subject(s)/Specialty: University(s)r: Countr : y: If completing a residency, residency training institution: Postgraduate year: APPLICATION FORM FOR POSTDOCTORAL FELLOWSHIPS FOR ACADEMIC DIVERSITY AT THE UNIVERSITY OF PENNSYLVANIA

3. PRIOR POSTDOCTORAL EXPERIENCE:

How many years of postdoctoral training have you completed? Yrs. How many previous postdoctoral positions have you held?

Last Last Institution: Department:

4. PRIOR TEACHING EXPERIENCE:

Institution(s) Position(s) held Course Title & Number(s) Dates .. to .. .. to .. .. to ..

5. RECRUITMENT:

How did you hear about Postdoctoral Fellowships for Academic Diversity? The Almanac BPP Website Advertisement (Journal Title: ) Recommended by mentor Word-of-mouth Other

Please identify three potential research mentors at Penn and the school in which you wish to study. This will help in the identification of potential research laboratories. Please also indicate if you have discussed the potential position with the mentor listed. Penn Mentor Mentor Name Mentor professional email School Contacted (Y/N)

Please list the three individuals who will submit letters of reference on your behalf:

Name Email Institution APPLICATION FORM FOR POSTDOCTORAL FELLOWSHIPS FOR ACADEMIC DIVERSITY AT THE UNIVERSITY OF PENNSYLVANIA

6. ADDITIONAL MATERIALS: 1) A curriculum vitae including current and pending publications

2) A personal statement, no longer than three pages, which addresses the following: . reviews your previous research accomplishments . outlines your future research goals and proposed research . describes your commitment to pursuing an academic career . and includes academic, employment or other life experiences that would bring new perspectives to the University community and your chosen field 3) Three letters of reference from people acquainted with the applicant’s work. One reference letter should be from the applicant's thesis advisor or faculty mentor. Reference letters must be submitted electronically on letterhead stationery in PDF format. Email subject line should be applicant's name followed by the words reference letter, e.g. Jane Smith_ Reference letter.

4) In addition, applicants are encouraged to a submit a letter from a Penn faculty member having similar research interests confirming that he/she is willing to serve as the applicant’s primary mentor during the fellowship period. This letter should be submitted with the application materials. Incomplete submissions will not be reviewed. If you have any questions please contact Josie Rook, Executive Director, Office of the Vice Provost for Research at [email protected].