UCLA T32 Program on Translational Neuroscience of Drug Abuse (TNDA) APPLICANT INFORMATION FORM

Applicant Name: Predoctoral Candidates Only

Mailing Address: Verbal GRE Score:

Telephone: Quantitative GRE Score:

E-mail Address: Analytical GRE Score:

Education – Post-High School Undergraduate GPA:

(Begin with baccalaureate and include previous postdoctoral training if applicable)

Institution City, State Degree Received Date Received

(Month and Year) Field of Study

Predoctoral Applicants Only Postdoctoral Applicants Only

UCLA Graduate Program: Name of Ph.D. Mentor:

Mentor Name: Proposed TNDA Mentor:

# Years of Previous NRSA Support: # Years of Completed Postdoctoral Experience: (Predoctoral NRSA support is limited to 5 years; 6 for dual degrees)

# Years of Previous NRSA Support: (Total postdoctoral NRSA support is limited to 3 years)

Demographic Information (for grant-reporting purposes only)

Sex: □ Male □ Female Are you of Hispanic or Latino origin or descent?

□ Yes □ No

What is your race? Please mark all that apply:

□ Asian □ Black or African American □ White □ Native American or Alaskan Native

□ Native Hawaiian or other Pacific Islander □ Other (please specify)

Citizenship: □ United States □ Other (please specify)

If other, are you a U.S. Permanent Resident? □ Yes □ No

Signature

I hereby verify that the above information is true and correct to the best of my knowledge and belief.

Trainee Applicant Signature: Date: