George P. Yang, MD, PhD Early Stage Investigator Award Application

URM Early Stage Investigator Award Application

"*" indicates required fields

Do not start this form unless you have all the necessary documents.

General Information

Name*

First Last Degree(s)

Email*

Current Academic Position*

Institution*

Primary Institution Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Institution Phone Number*

Primary Institution Department*

Are you doing your research year at another (secondary) institution?*

Yes

Secondary Institution*

Secondary Institution Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Institution Phone Number*

Secondary Institution Department*

Project Title*

Grant Category*

Basic/Translational

HSR/ Basic Science

Education

Describe how you meet the requirements of this award:*

Applicants should be those that are identified as BOTH underrepresented in medicine and an Early Stage Investigator as defined by the NIH

Letters of Recommendation

THREE letters of support must be included with your application.

1. REQUIRED SUS Member Sponsor
Please note, in order to meet the eligibility requirements, the SUS Member Sponsor must be a member in good standing of the SUS. If your sponsor is not certain of their SUS Membership status, they must contact the SUS Membership Services Department at [email protected].

2. REQUIRED Department Chair

3. REQUIRED Research Mentor/Collaborator

SUS Member Sponsor Letter of Recommendation*

Accepted file types: pdf, Max. file size: 512 MB.

Department Chair Letter of Recommendation*

Accepted file types: pdf, Max. file size: 512 MB.

Research Mentor/Collaborator*

Accepted file types: pdf, Max. file size: 512 MB.

Supporting Documents

All documents must be submitted in a PDF format.
Due to the number of files required with large file sizes, submission make take up to three minutes. Do not re-submit or leave the application page once you have clicked submit. You will be directed to a confirmation page once your application has been successfully completed.

Facilities and Resource Document*