2010 DHHS-HACU Professions Capacity Building Progr - Hispanic Association of Colleges and Universities

Required fields are indicated by an *.

Honorific

* First Name

* Last Name

* Title

* Department

* Institution

* Address

Address(Cont)

* City

* State

* Zip Code

* Phone

Extension

* Alternate/Cellular Number

FAX

Other:

* E-mail Address

* Alternate e-mail

* Emergency Contact

* Contact Phone

Full-time Faculty

Yes No

Full-time Staff

Yes No

* Number of years
at current institution

* Are you a US Citizen?

Yes No

If not, are you a legal
permanent resident?

Yes No

Educational Background - Please include year graduated, discipline and Institution.

Bachelor's:

Master's:

Doctorate:

Other:

Computer Literacy
(list of programs and
proficiency)

Faculty Only

Number of years of
college teaching

Academic Rank

  Assistant Professor
  Associate Professor
  Full Professor
  Research Professor
  Other, Please specify

Specific Discipline

Specific area(s) of
research:

Do you have any grant
writing experience?

Yes No

If yes, please list previous grants. Include project title, funder, amount, dates, and description

1 -

2 -

3 -

4 -

5 -

Optional Information

Gender (optional)

Male Female

Ethnicity (optional)

  American Indian
  Asian or Pacific Islander
  Black, Non-Hispanic
  Hispanic/Latino
  White, Non-Hispanic
  Other, Please specify

Additional Materials to be E-mailed (Required of all applicants):

Please e-mail the following documents to acuellar@hacu.net no later than April 23, 2010. Please note that both documents must be received before your application is considered complete.

Curriculum Vitae or Professional Resume (Word documents).

Statement of Personal Goals and Objectives: (Response must be 500-750 words, Times Roman double spaced in 12pt.)

Identify specific professional development goals, expected outcomes and current job related activities that demonstrate your level of interest and commitment to the project goals. In case of faculty applicants, state any ideas or proposals for research projects you are considering.

Additional Requirements

The program presentations will be held in San Antonio, TX and Bethesda, MD, usually in late Spring and during the Summer. The Bethesda week-long workshop (held generally during July) will include a visit to the National Institutes of Health (NIH). Potential applicants must be able to attend all program-related events. Specific dates will be announced once program participants are selected.

By clicking here, I agree to attend all of the aforementioned program activities. I also certify that all information and materials submitted in this application are true and accurate.

* I agree

* Date

,

* Print Name

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