Exit this survey >> SPR Minority Travel Award 2012 Question Title * 1. PLEASE COMPLETE THE FOLLOWING REQUESTED INFORMATION: FIRST NAME LAST NAME HIGHEST DEGREE POSITION DEPARTMENT INSTITUTION ADDRESS PHONE NUMBER FAX NUMBER EMAIL Question Title * 2. Race Ethnicity African American Latino (Specify) Asian, Pacific Islander (Specify) American Indian (Tribal Affiliation) Alaska Native Question Title * 3. CURRENT PREVENTION SCIENCE MENTOR(S) MENTOR 1 MENTOR 2 MENTOR 3 Question Title * 4. Are you currently a member of the Society for Prevention Research? You MUST be a member of SPR in order to be eligible for a travel award. If you are not a member, you must apply for membership at the same time as you send in this travel award application: https://secure.preventionresearch.org/membershipapplication.php YES NO Question Title * 5. Will you be presenting (oral or poster) at the meeting? YES NO Question Title * 6. If yes, indicate your abstract ID# 33% of survey complete. Next >>