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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 (Please check one) 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. Institution
City
State
Country
Dates of Attendance
Major - Area of Study
Degree Earned
Total Years of Training in US
2. Institution
City
State
Country
Dates of Attendance
Major - Area of Study
Degree Earned
Total Years of Training in US
3. Institution
City
State
Country
Dates of Attendance
Major - Area of Study
Degree Earned
Total Years of Training in US
ABSTRACT CATERGORY (please check one) Basic Science
Clinical Research
Translational Research

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
Upload Abstract
Upload Letter of Support

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