ASN YLS Young Latin Travel Awards Grant Form

ASN YOUNG LATIN STUDENT TRAVEL AWARD
ONLINE APPLICATION

(As it appears on your US Driver’s License or Passport)

Family Name:
Given Name:
Institution:
Department:
Street Address:
City:
State:
Zip/Postal Code:
Country:
Telephone (include country code):
Fax (include country code):
E-mail:
E-mail (again please):

PhD Students, Expected Date of Degree Conferment (day/month/year):
Postdoctoral Fellows, Date MD and/or PhD Conferred (day/month/year):

Students and Fellows:

Name of Research Director or Dissertation Supervisor:
Email address of Director or Supervisor:
Email address of Director or Supervisor (again please):

Independent Faculty Members:

Name of Department Chairperson
Email of Department Chairperson
Email of Department Chairperson (again please):

Young Latin Students:

Host Laboratory Primary Investigator:
Email Host Laboratory Primary Investigator:
Email Host Laboratory Primary Investigator (again please):
Senior Scientist providing recommendation:
Email recommending Senior Scientist
Email recommending Senior Scientist (again please):

Date of birth (day/month/year):

Abstract Title:

Authors (First author initials of first name then last name, initials second author then last name and so on):

Abstract (One paragraph containing: Introduction, Patients or Materials and Methods, Results, Conclusions. 250 word limit, spell out numbers and Greek letters, do not use symbols; do not include references):