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Minority Trainee Development Scholarship (MTDS)

2018 Minority Trainee Development Scholarship

(MTDS) program

DEADLINE – Sunday, March 11, 2018


PERSONAL & CONTACT INFORMATION

First Name/Given Name *
Middle Name/Middle Initial
Last Name/Family Name/Surname *
Degree/Designation *
Gender *
Male   Female  
NPI# (if applicable)
State License#
Ethnicity (Please check the one corresponding to the ethnic community with which you primarily self-identify) *
African American
Hispanic
Native American
Alaskan Native
Pacific Islander
Country of Origin or Birth Place *
Address *
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Phone Number *
Email *
Secondary Email
Have you been a previous recipient the MTDS award? *
Yes   No  
If yes, what year
Are you a Trainee? (i.e. including undergraduate and graduate or medical school, residency, fellowship) *
Yes   No  
Are you currently enrolled in a Trainee Program? (i.e. including undergraduate program, graduate program, medical school, residency, fellowship) *
Yes   No  
If you are enrolled in any other program, please explain:

ACADEMIC INFORMATION

Current University/Institution *
Address *
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Current position *

EDUCATIONAL INFORMATION : #1

1. Institution *
City *
State *
Country *
Dates of Attendance *
Major - Area of Study *
Degree Earned *
Total Years of Training in US *

EDUCATIONAL INFORMATION : #2

2. Institution
City
State
Country
Dates of Attendance
Major - Area of Study
Degree Earned
Total Years of Training in US

EDUCATIONAL INFORMATION : #3

3. Institution
City
State
Country
Dates of Attendance
Major - Area of Study
Degree Earned
Total Years of Training in US

AREAS OF INTEREST

Pulmonary Disease in *
Infants
Children
Adults
Aging
Epidemiology
Clinical Research
Health care disparities
Molecular/cellular biology
Animal models
Other
N/A
Sleep Medicine in *
Infants
Children
Adults
Aging
Epidemiology
Clinical Research
Health care disparities
Molecular/cellular biology
Animal models
Other
N/A
Critical Care in *
Infants
Children
Adults
Aging
Epidemiology
Clinical Research
Health care disparities
Molecular/cellular biology
Animal models
Other
N/A
Are you an ATS member? *
Yes   No  
If Yes, what is your ATS #
What other scientific societies do you belong to?
ACCP
SCCM
ERS
AAAAI
AASM
Other
If Other, please specify
Sponsor's Full Name *
Sponsor's Email *
Sponsor's Phone *
Abstract Category *
Basic Science
Clinical Research
Translational Research
Upload Abstract *
Upload Letter of Support *

Digital Signature

By my electronic or physical signature, I attest that the information I have provided here is accurate, and that I agree to the terms of the ATS MTDS Program, including attending the ATS International Conference from at least Sunday, May 20, 2018 – Monday, May 21, 2018, attending the Diversity Forum on Sunday, May 20, 2018 to receive the award, completing a survey following the ATS International Conference and keeping my contact information with the ATS current, regardless of my membership status. I further allow the ATS to contact me to solicit additional information on the progress of my career for a minimum of five years following my receipt of an ATS MTDS.

Applicant's Signature *