character length restrictions indicated. IRQ: CDRC Received: 08/05/2005 1. TITLE OF RESEARCH TRAINING PROPOSAL (Do not exceed 56 characters, in Sensory Processing in the Mouse Accessory Olfactory Bulb 2. LEVEL OF FELLOWSHIP 3. PROGRAMANNOUNCEMENT/REQUEST FOR APPLICATIONS Predoctoral PA-01-122 4a. NAME OFAPPLICANT (Last, First, Middle Initial) 4b. EMAIL ADDRESS 4c. HIGHEST DEGREE(S) Hendrickson, Rebecca C. hendricr@msnotes.wustl.edu B.S.I I 4d. PRESENT MAILING ADDRESS (Street, City, State, Zip Code) 4e. PERMANENT MAILING ADDRESS (Street, City, State, Zip Code) 5885 Nina PI. #2E Same as 4d St. Louis, MO 63112 4f. OFFICE TELEPHONE NO. 4g.HOME TELEPHONE NO. 4h.PERMANENT PHONE NO. 4i. FAX NUMBER (Area Code, No. and Ext.) (Area Code and No.) (Area Code and No.) (Area Code and No.) 314-265-8823 314-265-8823 314-265-8823 314-362-4461 U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL O PERMANENT RESIDENT OFU.S. 5. TRAINING UNDER PROPOSED AWARD (See Fields of Training) 6. PRIOR AND/OR CURRENT NRSA SUPPORT Discipline No.: Subcategory Name: (Individual or Institutional) 2920 Systems/lntegrative Neuroscience S NO D YES(If """"""""Ves,"""""""" refer toitem 24, Form Page 5) 7a. DATES OF PROPOSED AWARD 7b. PROPOSED AWARD DURATION 8. DEGREE SOUGHT DURING PROPOSED AWARD From (MM/DD/YY): Through (MM/DD/YY): (in months) Degree: Expected Completion Date: 12/01/05. 11/30/09 48 3 M.D./Ph.D;. '???-?? 12/2009 SPONSOR COMPLETES ITEMS 9 THROUGH 14 9. HUMAN 9a. RESEARCH EXEMPT 9b. HUMAN SUBJECTS 9c. NIH-DEFINED PHASE I 10a.VERTEBRATE ANIMALS 10b. ANIMALWELFARE SUBJECTS D NO Q YES ASSURANCE NO. CLINICAL TRIAL ASSURANCE NO. EH NO If 'Yes"""""""" Exemption No.: D NO;; D YES FWA00002284 D NO YES ^ YES ',"""""""" A3381-01, 11a. NAME OF SPONSOR (Last, First, Middle Initial) 11b. NAME OF PROPOSED SPONSORING INSTITUTION Holy, Timothy E. Washington University Telephone: 314-362-0086 Address: 660 S. Euclid AV6. Fax;314-362-4461 St. Louis, MO 63110 Email: holy@wustl.edu 11c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT Division of Biology &Biomedical Sciences 11d. MAJOR SUBDIVISION 12. ENTITY IDENTIFICATION NO. DUNS NO. School of Medicine 1430653611A1 06-855-2207 13. NAME AND TEL. NO. OF ADVISOR IF DIFFERENT FROM 11a. 14. NAME OF OFFICIAL IN BUSINESS OFFICE John Michnowicz Telephone: Telephone: (314)747.4134 Name and address of institution where research training will take place if Fax: (314)362-0315 different from Item 11b. Title: Director, Grants and Contracts Address: Address: Washington University 660 S. Euclid Ave. St. Louis, MO 63110 Email: G&C@msnotes.wustl.edu 15. APPLICANT CERTIFICATION AND ACCEPTANCE: I certify that the statements herein aretrue, complete, and accurate to the best of my knowledge, and I agree to comply with the terms and conditions of award if an award is issued as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I certify that I have read the Ruth L. Kirschstein National Research Service Award Assurance, that I will abide by the Assurance if an award is made, and that the award will not support residency training. SI 'URE (Requin >apofcam) DATE July 14, 2005 PHS416-1 (Rev. 06/02) Face Page (Form Page 1) PART I (Form Pages 1to 6,9) Kirschstein-NRSA Individual Fellowship Application (To becompleted byapplicant - follow
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