Application for University of Florida Substance Abuse Training Center in Public Health Last Name First Name Middle Name Permanent Address - Street City State Zip Country Telephone: (Business) Telephone: (Home) Email Address: ( ) ( ) U.S. Citizen: IF NOT A U.S. CITIZEN: Yes No Permanent Resident: Yes U.S. Non-Citizen National: Yes No No Equal Opportunity/Affirmative Action We are required by NIH to collect the following information for reporting purposes. The University of Florida is committed to a policy of equal opportunity and affirmative action in the appointment process. We welcome and encourage applications from underrepresented minorities, women, and persons with disabilities. □ □ Gender: Male Female Race/Ethnicity (check all that appy) □ □ □ □ □ American Indian Native Hawaiian or Pacific Islander Asian Hispanic or Latino/a Black/African-American □ □ White (Non-Hispanic) Intentionally Withheld Emergency Contact: Name/Telephone # Address Relationship Colleges, Graduate and Professional Schools Attended: Degree or Expected Institution Name City & State Dates of Attendance Date Major to to to Previous Fellowships Supported by USPHS: Location Program Title Dates Were you ever required to leave any college or professional school (e.g., suspension or dismissal) or denied readmission for any reason? Yes No If “yes” explain fully. YOU MUST ANSWER THIS QUESTION. (Attach additional sheet if necessary) □ □ Application for: Pre-doctoral fellowship Post-doctoral fellowship  Have you visited our website? Yes
Application for University of Florida Substance Abuse Training Center in Public Health Last Name First Name Middle Name Permanent Address - Street City State Zip Country Telephone: (Business) ( ) Telephone: (Home) ( ) Email Address: U.S. Citizen: Yes No IF NOT A U.S. CITIZEN: Permanent Resident: Yes No U.S. Non-Citizen National: Yes No Equal Opportunity/Affirmative Action We are required by NIH to collect the following information for reporting purposes. The University of Florida is committed to a policy of equal opportunity and affirmative action in the appointment process. We welcome and encourage applications from underrepresented minorities, women, and persons with disabilities. Gender: □ Male □ Female Race/Ethnicity (check all that appy) □ American Indian □ Native Hawaiian or Pacific Islander □ Asian □ Hispanic or Latino/a □ Black/African-American □ White (Non-Hispanic) □ Intentionally Withheld Emergency Contact: Name/Telephone # Address Relationship Colleges, Graduate and Professional Schools Attended: Institution Name City & State Dates of Attendance Degree or Expected Date Major to to to Previous Fellowships Supported by USPHS: Location Program Title Dates Were you ever required to leave any college or professional school (e.g., suspension or dismissal) or denied readmission for any reason? If “yes” explain fully. YOU MUST ANSWER THIS QUESTION. (Attach additional sheet if necessary) Yes No Application for: □ Pre-doctoral fellowship □ Post-doctoral fellowship Have you visited our website? Yes 
T32%20Application.docx