Theoretical and Computational Neuroscience

Directions for Completing Application:

Complete the form below using the "tab" key to move between fields.
Keep a copy of the text of your Mentoring Plan and provide a copy of the Plan to your Mentor.
If you would like a copy of your application, print the application prior to submission. For some text fields, such as project description, layperson's description, etc., the printed copy will only show a portion of the text. You should keep a separate copy of these items for your reference.
If you have any questions, contact Amy Jackson, amyjackson@rice.edu

NOTE: Prior to submission of this application, you must talk with your institution's Neuroscience Program Institutional Representative. See application requirements. Applications submitted without Institutional Representative approval may not be considered.

Information in red is required.

APPLICATION FORM

Name of Institutional Representative contacted:

Level PreDoctoral

Applicants may be referred to other Keck Center training programs if it appears the applicant's interests are aligned with the aims of the other programs. Check here if you do not want your application referred to other Keck Center programs:

No, do not refer my application to other Keck Center programs.

Applicant
First Name		Last Name		Middle
Gender		Ethnicity	(optional)
Primary Email		URL
Birthplace	City, State, Country	Birthdate	(mm/dd/yyyy)

Permanent Address

Address 1
Address 2
City	State	Zip
Country	Phone

Current Address

Valid Until

(mm/dd/yyyy)

Address 1

Address 2

City

State

Zip

Country

Phone

Work Phone

Fax

U.S. Citizen	Yes No If no, please complete: Citizenship Status, Visa Type, and Visa Number
Citizenship Status
Visa Type
Visa Number

Education
Current Institution
GCC Member Institution
Other Institution

Department
Current Mentor / Advisor
Current Mentor / Advisor Department

Have you taken a Biomedical Ethics course? Yes No
Please provide information about the Biomedical Ethics course taken. Please include plans for this course as part of your mentoring plan.

For Predoctoral Applicants:
Anticipated Degree Month/Year	(mm/yyyy)

All Applicants

	Other Institution(s) Attended and Location (City, State, Country if other than U.S.) Most recent first	Degree and Field of Study	Degree Date (mm/yyyy)	Grade Point Average
1st					For date and GPA enter 0's for non-applicable.
2nd
3rd
4rd

Testing Information

GRE General
	Raw	Percentile		Raw	Percentile		Raw	Percentile
Verbal			Quantitative			Analytical

GRE Subjects

Subject Name

Raw

Percentile

TOEFL

Grant Support
Please list any previous grant support (federal or otherwise) and dates of the support.

Keck Center Fellowship Information

Primary Mentor		and Institution
Co-Mentor		and Institution
Desired Start Date		Fellowship Type

Provide 6-8 keywords describing your research area:
1:	2:	3:	4:
5:	6:	7:	8:


Project Title
Project Description max. 750 words
used words (max. 750 words)


Layperson's Project Description max. 250 words Note: A layperson’s project description is a simple description that would be understandable by someone with only basic science background. It is for general purpose use.
used words (max. 250 words)


Career Goals max. 500 words Describe your overall career goals and how they relate to this training program. Describe the education, training and other career development experiences you will need to achieve your career goals, and how this program will help you achieve them.
used words (max. 500 words)


Mentoring Plan max. 400 words Mentoring and Training Plan Please provide a brief description, in your own words, of the plan you and your mentor have jointly developed to achieve your career goals. Include anticipated didactic course work, anticipated research training, enrichment activities and personal development (e.g. writing and speaking skills), professional meetings to be attended, etc. The plan should include an estimated timeline for completion of the graduate or postdoctoral training program and specific milestones to be achieved.
used words (max. 400 words)

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