Online Application

On-Line Applications and Supporting Materials must be received by March 10, 2008.
You will be notified of your acceptance no later than March 21, 2008.

Fields with an asterisk (*) are REQUIRED

Applicant Type:
      

Applicant Information
Professional title: Academic title:
Administrative title: Clinical title:
First name:* Last:*
University/Institute:*
Office Street address:*
Office City:* Office
State:*		 Office
Zipcode:*
Home address:*    
Home City:* Home State:* Home Zipcode*:
Telephone (office):* Fax (office):*
Cell Phone:*    
Email:* Alternate
E-mail:		  
Degree(s):

 Year(s) obtained:
Specific areas of interest*:
Mailing address
(if different from above):

Emergency Contacts
Contact name*:
...Home phone*:
...Work phone*:
...Cell phone*:
Alternate Contact name*:
...Alt. Home phone:*
...Alt. Work phone*:
...Alt. Cell phone*:
Health Insurance Company*:
Policy Number*:
Any special medical or personal information you would want an emergency care provider to know?

Transportation / Needs / Restrictions
Travel method*: Flying    Driving
Other (Please specify: )
Special needs:
Dietary restrictions:
   (e.g., low-carb, vegetarian... please be very specific)
Faculty Only
Date of presentation:
Time of presentation:
A/V Needs:
I do NOT need any A/V equipment
Laptop Projector
Overhead Flip-Chart

W-9 Form: (Sue Diesel will inform you if you are required to complete this form)

Link to W-9 Form on IRS Site
(will open in another window)
  

Faculty Bio:

Please include your bio:
(approximately 225 words or 15 lines)


 

Registration Agreement
As this is a federally funded project, if for any reason you should need to decline participation or cancel your reservations after they have been confirmed, you will be responsible for all costs that have been assumed on your behalf. We will work with you to make the best arrangements possible, however, we cannot, as stewards of grant funds, be responsible for expenses incurred if you do not attend the institute.

After submitting this application, you will be asked to attach the supporting materials listed at the right in a separate email to:



Sue Diesel
sue_diesel@urmc.rochester.edu
University of Rochester Medical Center
300 Crittenden Blvd., Box PSYCH
Rochester, NY 14642
585-275-3571 (phone)
585-275-6666 (fax)

 

 

Supporting Materials Checklist

  • A curriculum vitae that includes your current address, telephone and fax numbers, and e-mail address, and a listing of authored publications, where appropriate.

  • A one page statement of your research and career interests.

  • Under separate cover, a letter of reference from your program training director, for Level 1 applicants, or your department chair or post-doctoral program director for Level 2 applicants. This must include a clear, succinct description of your current performance, future plans, and potential for developing as an independent investigator devoted to understanding or preventing suicide, attempted suicide, or critically related risk factors. For potential Level 2 participants, this letter also should include a statement of institutional support for the applicant’s career development plans.

  • Each Level 2 participant will be expected to send a two page synopsis of his/her emerging grant proposal one month prior to the SRI/SP.