SPR Minority Travel Award 2012

Question Title

1. PLEASE COMPLETE THE FOLLOWING REQUESTED INFORMATION: (Required.)

FIRST NAME

LAST NAME

HIGHEST DEGREE

POSITION

DEPARTMENT

INSTITUTION

ADDRESS

PHONE NUMBER

FAX NUMBER

EMAIL

Question Title

2. Race Ethnicity (Required.)

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 (Required.)

YES

NO

Question Title

5. Will you be presenting (oral or poster) at the meeting? (Required.)

YES

NO

Question Title

6. If yes, indicate your abstract ID#

33% of survey complete.