Division 40 Career Development Travel Award

DIVISION 40 CAREER DEVELOPMENT TRAVEL AWARD APPLICATION CHECKLIST

Signed Application Face Page

Career Plan Summary (not to exceed 5 pages)

Curriculum Vitae (Note: Include only published and “in press” manuscripts in the Publications section. Published abstracts, presentations, submitted manuscripts, and manuscripts in preparation may be listed in bibliography under separate headings).

Letter of Support from Mentor (or request for a mentor, if needed)

Note: Applicants are not required to submit a proposed budget for the travel award; however, award winners will be required to complete and submit an APA travel expense record form before being reimbursed for travel expenses. A sample of this form is provided for review.

INSTRUCTIONS: All materials are to be submitted electronically to David W. Loring, PhD, Chair, Awards Subcommittee, at [email protected]. This includes the completed application face page and mentor’s letter or support. Signatures are not required for electronic submission of these materials.

In addition, applicants must print and send a signed copy of the completed application face page to:

David W. Loring, PhD Chair, Awards Subcommittee APA Division 40 McKnight Brain Institute University of Florida PO Box 100236 Gainesville, FL 32607-0236

Deadline for receipt of ALL application materials is January 5. APA Division 40 LEAVE BLANK—FOR DIV40 USE ONLY. Travel Grant Application Date Received: Application # Please Follow instructions carefully. Date Reviewed: Ranking:

1a. APPLICANT NAME (Last, first, middle) 1b. Degree 1c. Sex Male Female

1d. CURRENT POSITION (Check one and indicate year of training) 1e. Ethnicity (Optional): Graduate Student Current Yr of Training Postdoctoral Resident Current Yr of Residency

1f. MAILING ADDRESS (Street, city, state, zip code) 1g. INSTITUTION

1h. DEPARTMENT/DIVISION

1i. TELEPHONE AND FAX (Area code, number and extension) 1j. E-MAIL ADDRESS: TEL: FAX:

2. APA MEMBERSHIP STATUS: 4. MENTOR INFORMATION Member If no mentor is available, check here and one will be provided Student Affiliate Name Associate Address NonMember Phone Other ______FAX 3. TYPE OF ORGANIZATION/INSTITUTION Email University/College Academic Medical Center Hospital/Clinic Private Practice Other (Describe):

5. APPLICANT ATTESTATION: If a travel grant is awarded as a result of this application, I agree to serve on a Div40 governance committee (to be determined) for a minimum of one year. I also understand and agree to the following conditions:  The maximum award is $2500  A completed travel expense report is required for reimbursement.  Original itemized receipts are required for expense reimbursement. Credit card slips are not sufficient unless accompanied by an original itemized receipt.  Reimbursement for airfare is only available for coach travel.  Meals will be reimbursed up to $75 per day. Div40 does not reimburse for alcohol.  Hotel stays will be reimbursed up to $200 per day, excluding taxes. Div40 does not reimburse for hotel entertainment (in-room movies, health club fees, etc).  Ground transportation (taxi fare, airport parking) will be reimbursed up to $150.

SIGNATURE OF APPLICANT NAMED IN 1a. DATE

SIGNATURE OF MENTOR NAMED IN 4 (leave blank if requesting a mentor). DATE

Note: Please submit an unsigned copy of this application form electronically together with other application materials. Applicants must also mail a signed and dated copy of this face page to: David W. Loring, PhD, Chair, Awards Subcommittee, APA Division 40, McKnight Brain Institute, University of Florida, PO Box 100236, Gainesville, FL 32607-0236. Applicant Name (last, first, middle):

CAREER PLAN Do Not Exceed 5 Pages. Use 12pt font or larger

Note: Applicants should strive for a comprehensive yet concise review of their background, interests, future goals, etc. Use continuation pages as needed. It is not required that a full five pages be used to convey this information.

A. BRIEFLY DESCRIBE YOUR TRAINING BACKGROUND:

B. WHAT ARE YOUR CAREER INTERESTS? Over the next 5 years, what job/position would you like to pursue and in what type of setting do you plan to work? To what extent do you plan to be involved in teaching, research, and clinical practice? In what areas do you wish to ultimately demonstrate specific expertise and excellence?

C. WHAT ARE YOUR CURRENT RESEARCH INTERESTS & FUTURE RESEARCH GOALS? How do you plan to implement these goals over the next 5 years? How does this fit with your overall career objectives?

D. WHAT ARE YOUR THOUGHTS ABOUT ACADEMIC/PROFESSIONAL COMMITTEE SERVICE? Are you currently involved in any committee service in your institution or within the professional field? How does committee service and governance fit into your career plan?

E. HOW WOULD ATTENDING THE DIV40 PROGRAM AT THE ANNUAL APA CONVENTION FACILITATE YOUR CAREER GOALS?

F. IN WHAT WAYS MIGHT DIV40 BETTER FACILITATE PROFESSIONAL DEVELOPMENT IN EARLY CAREER NEUROPSYCHOLOGISTS AND STUDENTS? (Note: This question is intended to help Div40 develop resources for early career neuropsychologists. Answers to this question will not be judged as part of the application/awards process)

TRAVEL EXPENSE REPORT APA Division 40 EARLY CAREER DEVELOPMENT TRAVEL AWARD Date of Request: Meeting Attended: Name: Date(s): Mailing Address: Location: Phone: Email: Budget to Charge To (Name of Office or Committee): Science Advisory/Awards DATES TOTAL Transportation* Airfare Taxi/car rental Parking/tolls Mileage Lodging** Meals*** Breakfast Lunch Dinner Miscellaneous (itemize)

Signature:

PER APA POLICY, ORIGINAL ITEMIZED RECEIPTS ARE REQUIRED FOR ALL EXPENSES. Enclose receipts in an envelope or tape them to blank sheets of paper. Credit card slips without itemized receipts are not eligible for reimbursement.

*If driving rather than flying to convention, mileage will be reimbursed $0.485/mile (eff. 01/2007). Ground transportation (taxi, parking) is reimbursed up to $150.

**Room Rates are reimbursed up to $200 per night, exclusive of hotel tax.

***Meals are reimbursed up to $75 per day. Div40 does not reimburse for alcohol.

Send completed Travel Expense Form with original receipts to:

Jacobus Donders, Ph.D. Treasurer, APA Division 40 235 Wealthy SE Grand Rapids, MI 49503