Substance Abuse and Mental Health Services Administration
Minority Fellowship Program
Fellowship Application Form


Application Name:
Last   First   Middle Maiden

Credentials: 
Specialty Licensure:
 
Home Address: 
City:    State:    Zip:

Preferred Mailing Address: (If different from above)
City:    State:    Zip:
 

Telephone Number:
Home:     Work:   Fax: (if available)

Email: 
Home: Work:

US Citizen? 		 
Yes No Proof of Permanent US Residency:  
  (Provide the number of residency card)
 
Sex:  Female Male
Birthdate: Month  Day   Year   

Birthplace: 
City/County:   State:      Country:

Marital Status: 
Single   Married    Widowed    Separated

Ethnicity and Racial Identification: All applicants, based on self identification, should select one category under Ethnicity and one category under Race.

Ethnicity:
Hispanic or Latino    Non-Hispanic or Latino

Race:
Asian American                  Native Hawaiian/Pacific Islander
African American/Black         American Indian/Alaska Native
Other (Please Specify)

State in which you hold a license to practice as a Registered Nurse:  
License #:
Proposed Institution of Study:
Address:
City: State:   Zip:

Identify your advisor at the proposed Institution of Study:
Advisor Name:
Mailing Address:
City:  State:   Zip:
Telephone #:    Fax:
Email:

Title of Proposed Dissertation Research:

Present Position/Title:

Educational Background (Please Complete all items, if not applicable put "N/A")
Institution
(Begin with Most Recent)		 Location
(City/State/ Country)		 Dates Attended
( From - To)		 Major Area of Study Degree

(a) Doctoral GPA:
(b) Masters GPA:
(c) Cumulative overall undergraduate nursing GPA:
(d) Cumulative overall undergraduate GPA:

Check the box which best describes the current educational program in which you are enrolled:
Doctoral
Masters
Masters/Doctoral
BSN/PhD
BS/PhD
Nursing as Second Degree
Other (Describe)

If you checked any of the items above, please complete the following information. If not, proceed to the next item.
University
Location
(City, State)   
Dept. Affiliation
Name of Advisor
Date you entered the program:   Month   Year
Do You plan to continue studying here? Yes No
If no, please explain. If accepted in to MFP identify the doctoral program where you will matriculate as a Fellow:

List the name, title, and address of three persons in academic institutions or community/work settings who will provide letters of recommendation on your behalf by evaluating your ability to successfully complete your graduate program. These three professionals must be able to evaluate your potential for graduate study, and attest to your capacity to complete doctoral work in the area of substance abuse and mental health disorders and prevention/ treatment. Each of the three individuals should be instructed to complete the Letter of Recommendation form and mail or fax it directly to the MFP as indicated on the form.

NAME TITLE ADDRESS/TELEPHONE NUMBER
 
Please identify any other current or anticipated sources of funding such as government, foundations, private, faith-based, etc. (If not applicable, please put "N/A")

Name of Organization:
Amount of Funding:
Duration of Funding: