CLINICAL RESEARCH SCHOLARSHIP FORM Clinical Research Scholarship Registration Form Name* First Last Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneRho Chi Chapter Year of Initiation Fellowship Director Director's Email Address where you may be reached during the summer months (if different than above).Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code ReferencesProvide the names of three individuals who will provide letters of reference. Letters of reference or recommendation should be from individuals directly familiar with you and should speak specifically to your educational achievements and your capacity for graduate study. All letters should be emailed directly to the Society’s National Office marked Attention: Chair of the Clinical Research Scholarship Committee. SUPPORTING DOCUMENTS (ON SEPARATE SHEETS)1. Submit transcripts from all colleges or universities attended (photocopies are acceptable). 2. Provide your present title and affiliation and provide an abbreviated description of your fellowship program. (Maximum 2 pages) 3. Enclose your Curriculum Vitae 4. Briefly describe any previously completed (undergraduate or pre-doctoral) research projects. (Maximum 2 pages) 5. List any research-related poster or platform presentations, published abstracts, and/or published articles. (Maximum 2 pages) 6. Provide a narrative that addresses what you expect to accomplish during the second year of your fellowship, the projected impact of your work, and how your fellowship work relates to your career goals. (Maximum 3 pages)Mail one (1) copy of the completed application, supporting documents, and letters of recommendation to arrive no later than December 15 to the following address, or email one PDF copy of all application materials to firstname.lastname@example.org: The Rho Chi Society C/O University of Michigan, College of Pharmacy Attn: Clinical Research Scholarship Committee 428 Church Street Ann Arbor, MI 48109-1065You will be notified by email when the completed application has been received.