Application Form
The CIS Foundation Committee is pleased to award up to five CIS Foundation Scholar Grants to support education that promotes excellence in research and/or patient care, innovation in immunology, and the advancement of advocacy efforts. The grants are intended to support the development of the clinical immunology community and advance the goals of CIS. While the number of grants awarded each year may vary (maximum 5 a year), the total amount of all grants awarded annually will not exceed $25,000.
Applicant Contact Information
Name
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First Name
Last Name
Email
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example@example.com
Institution:
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Training Graduation Date (MM/DD/YYYY):
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Personal Statement
Personal statement (maximum 1 page, single spaced, 11pt font) that addresses: A) Why this mentored learning experience is of interest to them and will benefit their career. Uploads must be in .pdf format.
Personal Statement
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Mentored Learning Experience - Read carefully and submit all applicable materials
Mentored learning experience proposal (maximum 2 pages, single spaced, 11pt font). Should include the following: 1) Description of mentoring activities to be conducted during the grant period; 2) Brief description of why/how the mentor was selected and the unique resources available at the mentor host program to support the awardee’s mentored activities; 3) Goals and projected outcomes of mentored learning experience; 4) Timeline for achieving goals and proposed outcomes during grant period; 5) Detailed budget for use of fellowship funds. Uploads must be in .pdf format.
Mentored Learning Experience
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Applicant CV Upload (.pdf only)
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Mentor CV Upload (.pdf only) - NOTE: If mentor’s CV does not include a detailed mentoring section, the applicant must also submit a statement of mentoring activities/record for the mentor in the optional space below.
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Optional - If mentor’s CV does not include a detailed mentoring section, the applicant must also submit a statement of mentoring activities/record for the mentor
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Letter of Support
Letter of Support from the applicant’s primary Department Chair or Division Chief, which must address the approval of leave to pursue the mentored learning experience The letter writer must sent the LOR directly to the CIS Executive Director, Madeleine Hanan, at mhanan@clinimmsoc.org. LORs that are not received by the February 16th deadline are considered incomplete and ineligible for consideration.
I have or will have my letter writer send the LOS directly to mhanan@clinimmsoc.org to complete my application:
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I agree
Letter from Mentor
Letter from mentor confirming his/her interest and ability to host and mentor the applicant, as well as assist with the stated goals of the mentee The letter writer must sent the LOR directly to the CIS Executive Director, Madeleine Hanan, at mhanan@clinimmsoc.org. LORs that are not received by the February 16th deadline are considered incomplete and ineligible for consideration.
I have or will have my letter writer send the LOR directly to mhanan@clinimmsoc.org to complete my application:
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I agree
Financial Conflicts of Interest Statement(s)
For each applicant, list real or potential financial conflicts of interest with the proposed studies. Financial conflicts of interest would include direct payments from corporate entities related to the proposed experience and/or investments that would benefit the applicant or the applicant's family as a result of the proposed studies.
Enter all real or potential conflicts of interest in the space provided. Type "None" if none.
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