Persian1: L0011468 Credit: Wellcome Library, London

Department of Physiology and Cell Biology

2013 Margaret T. Nishikawara Scholar and Pillar Awards for PhD and MD/PhD Students Application Form (to be submitted to be considered for either or both award types) All items must be completed for full consideration for any of the awards. This form must be submitted with a CV (see example below), a copy of the abstract submitted to the 2013 Physiology Research Day, and an essay (500 word maximum), describing your reasons for pursuing a PhD in Physiology and Cell Biology and your short and long term career goals. All applications materials are due by 5:00 PM February 22, 2013.

1. Applicant’s Name ______, ______Last First MI

2. Primary Advisor of Record ______, ______Last First MI

3. Graduate Program (IBGP, Biophysics, NGSP, MCDB, OSBP) ______

4. Degree sought and anticipated year of completion ______, ______(PhD, MD, MD/PhD) (year)

5. Month and year first enrolled in current graduate program ______Month, Year

6. Month and year of written and oral candidacy exam (if completed) ______Month, Year

7. Applicant Acknowledgement: I confirm that all application materials were completed by me and facts are true to the best of my knowledge. The required essay was completed without help or guidance from my advisor or other faculty members.

______Applicant Signature Date

8. Advisor Acknowledgement: I confirm that I am a full time faculty member with a primary appointment in the Department of Physiology and Cell Biology. The student listed above is enrolled in good standing in a PhD or MD/PhD program affiliated with the OSU College of Medicine and School of Biomedical Sciences and is completing his or her dissertation research in my laboratory.

______Advisor Signature Date

All parts of this application should be compiled in the order below and sent as a single pdf attachment to Dr. Lyn Jakeman ([email protected]) by 5:00 PM on February 22, 2013.

Checklist: ____ Application ____ CV (complete and annotated – see example) ____Abstract (for 2013 PCB research day) ____Essay/Statement (500 word max) Curriculum Vita – Suggested MODEL for Nishikawara Scholarship Application 2013 Joe F. Student Lab: 614-292-1234 304 Hamilton Hall Fax: 614-292-4888 1645 Neil Avenue e-mail: [email protected] Columbus, OH 43210 Education Month, 20xx-Present The Ohio State University, Columbus, OH Pursuing Ph.D. in XXX program * Candidacy Exam completed x/x/20xx (* if applicable) Research Mentor: Dr. xxxyyyzzz 20xx-20xx The Major University of XYZ B.S. Degree of Choice Teaching Experience Month, 20xx List all teaching experiences and dates including TAs and/or mentoring undergraduate researchers. Include formal tutoring or test prep classes. Provide a brief description of your role and number of hours per week . Memberships and Service Dates Student Membership in the xx Society. Dates Student Representative on College, Department, Local or National Committees Dates Other service relevant to your profession to the community or university Expand with a brief description. Research Experience Funded Awards and Financial Support Received as a Graduate Student Month 20xx List all awards and dates including travel awards, merit awards, grants and other support All Applications for Awards submitted and pending decision, or not funded Month 20xx Agency, Award Name, Score. (examples, NRSA predoctoral or training grant applications) Note: Do not include abstracts submitted but not awarded prizes in poster competitions in this section. Previous Research Internships and other Research Experience (prior to OSU program) Dates Research Facility or Institution and Advisor For each entry, Add brief description: (i.e. Trained primates in behavioral tasks, carried out research project on effects of ….) Oral Research Presentations Dates Title of talk, audience or group, where it was presented Publications Peer Reviewed Manuscripts List all published papers Submitted Manuscripts List all submitted papers, including papers in revision Abstracts Include where abstract was presented and dates