Clinical Trials Fellowship

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Thank you for your interest in applying to the Clinical Trials Fellowship offered by ITMAT Education.

Only one application is required for both the Fellowship Program and Scholarship. All eligible applicants who apply during the fall application cycle are considered for the scholarship.

In addition to this application, please have your Primary Mentor submit a Letter of Support to Jessica German at jbgerman@upenn.edu. Details on information for this letter are included on the website:

http://www.itmat.upenn.edu/ClinicalTrialsFellowship/

First Name

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Last Name

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Degree Credentials (ie MD, PhD)

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Email Address

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Phone Number

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Permanent Home Mailing Address (street, city, state, zip)

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Date of Birth

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M-D-Y

Country of Birth

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Citizenship Status

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What type of visa do you have?

For federal and state reporting purposes, how do you identify your sex?

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What is your native language?

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If other, please list your native language

Do you speak any other languages?

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Which language?

Ethnicity

The University of Pennsylvania does not discriminate with regard to race, color, sex, religion, national origin, sexual orientation or handicap; the information requested is for reports the University provides to Federal authorities and to other agencies collecting data on equal opportunity for education and employment. In addition, the School uses the information to identify segments of our applicant pool in order to provide information about specific topics or events.

Please check one or more of the following groups in which you consider yourself to be a member.

American Indian or Alaska Native (including all Original Peoples of the Americas)

Asian (including Indian subcontinent and Philippines)

Black or African American (including Africa and Caribbean)

Native Hawaiian or Other Pacific Islander (Original Peoples)

White (including Europe, North Africa, and Middle East)

Which best describes your background?

Are you Hispanic or Latino (including Spain)?

Do you come from a family with an annual income below established low income thresholds?

Are you the first generation in your family to attend college?

Do you have a disability (a physical or mental impairment that substantially limits one or more major life activities)?

If you are a member of a community that has historically been underrepresented in higher education and would like to tell us how this particular perspective adds to the value you will contribute to the diverse learning community we strive to create, please do so here.

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Place of Employment

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Department or Division

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Position Title (current)

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Position Title (expected as of July 1 2021)

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Title of your proposed research project

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Primary Mentor First Name

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Primary Mentor Last Name

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Primary Mentor Degree Credentials (ie MD, PhD)

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Primary Mentor Email

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Curriculum Vitae

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Personal Statement

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Research Statement

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Other Support (Applicant)

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Statement by the Applicant - I hereby certify that I have provided accurate information in this application and that this application is my own, honest statement to the Admissions Committee.

I understand that materials submitted are subject to verification. I authorize all persons or entities to provide any relevant information in their possession to the University of Pennsylvania or its agent for use in considering my application for admission or verifying all of the application materials I have submitted, and I understand that the University does not notify applicants about any aspect of its verification procedures. Any misrepresentation, omission, or academic integrity violation in my application or supplemental materials will justify denial of admission, rescission of admission and/or financial aid, expulsion, or revocation of a degree if discovered at a later date.

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