SAMHSA Minority Fellowship Application Form

APA/APAF
SAMHSA funded Minority Fellowship Application Form
This project is supported by funds from the Substance Abuse and Mental Health Service Administration (SAMHSA), Department of Health and Human Services (DHHS), under the Minority Fellowship Program

PARTICIPATION IS LIMITED TO ONLY ONE FELLOWSHIP PROGRAM AT A TIME.

1) applications must be completed and submitted in one sitting; there is no option to start then finish later and
2) applications must be submitted on a PC or laptop; smart phones or tablets are not suitable.

1. Application Year *This question is required.

2. APA Membership #: (If Applicable)

3. Current PGY Level:
Must be at least a PGY-2 and remain in training the entire duration fellowship. *This question is required. This question requires a valid number format.

4. What is the duration of your training program? *This question is required. This question requires a valid number format.

5. Projected PGY Level by July 30 of the Fellowship year for which you are applying: *This question is required. This question requires a valid number format.

BIOGRAPHICAL/DEMOGRAPHIC INFORMATION

6. Applicant Information *This question is required.

First Name

Last Name

Level of Education (i.e., M.D., M.P.H.)

Street Address

Apt/Suite/Office

City/ State (Initials)

Zip

Country

SSN

7. Preferred Phone: *This question is required.

8. Preferred Cell Phone *This question is required.

9. Email (to be used to notify applicant): *This question is required.

Preferred Email
Alternate Email

10. Gender:

11. Sexual Orientation: (APA/APAF is required to report to SAMHSA) *This question is required.

12. Country of Citizenship: *This question is required.

If not a U.S. citizen, are you a permanent visa resident?

13. Ethnicity/Race: (APA/APAF is required to report to SAMHSA)
*This question is required.

14. Are you Spanish/Hispanic/Latino?
*This question is required.

Current Training Program Information

16. Name of Institution: *This question is required.

17. Institution Address: *This question is required.

Address 1
Address 2
City
State (Initials)
Zipcode

18. General or Sub-specialty Training: *This question is required.

19. Date From: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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20. Date To: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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21. Current Training Director Name: *This question is required.

22. Address: *This question is required.

23. Email: *This question is required.

As of July of the year for which you are applying: (if different from above)

24. Future Training Director Name: *This question is required.

25. Address: *This question is required.

26. Email: *This question is required.

PROFESSIONAL INTERESTS

27. Please specify your professional interest areas.

1.
2.
3.

OTHER INFORMATION

28. Have you ever applied to an APA resident fellowship? *This question is required.

If so, list program name and year applied

29. Have you ever received an APA/APAF resident fellowship? *This question is required.

If so, list program name and year received:

30. Do you plan to work with minority groups and/or underserved persons after training is complete? *This question is required.

If yes, please specify in a brief statement, limited to 500 characters:

31. How did you learn about this program? *This question is required.

Your PDF uploads must fully meet all application requirements. Click link to return to specific requirements.

32. Curriculum Vitae (50MB limit)
PDF naming structure: (FirstName-LastName-CV.pdf) PDF naming example: John-Smith-CV.pdf *This question is required.

File: {{filename}} delete

33. Personal Statement (50MB limit)
PDF naming structure: (FirstName-LastName-PS.pdf) PDF naming example: John-Smith-PS.pdf *This question is required.

File: {{filename}} delete

34. 1st Letter of Recommendation (50MB limit)
PDF naming structure: (FirstName-LastName-1stLetter.pdf) PDF naming example: John-Smith-1stLetter.pdf *This question is required.

File: {{filename}} delete

35. 2nd Letter of Recommendation (50MB limit)
PDF naming structure: (FirstName-LastName-2ndLetter.pdf) PDF naming example: John-Smith-2ndLetter.pdf *This question is required.

File: {{filename}} delete

36. 3rd Letter of Recommendation (50MB limit)
PDF naming structure: (FirstName-LastName-3rdLetter.pdf) PDF naming example: John-Smith-3rdLetter.pdf *This question is required.

File: {{filename}} delete

37. Proposed Budget Plan (50MB limit)
PDF naming structure: (FirstName-LastName-PBPlan.pdf) PDF naming example: John-Smith-PBPlan.pdf *This question is required.

File: {{filename}} delete

38.

A statement (no more than one page) describing how funds will support the mission of the Fellowship (50MB limit).
PDF naming structure: (FirstName-LastName-BudgetStatement) PDF Naming Example: John-Smith-BudgetStatement

File: {{filename}} delete

39. Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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All materials must be received together by 11:59:59 PM Eastern Standard Time, January 31, 2019.

Incomplete documentation upload may be grounds to reject the entire application.