# ![](media/image1.wmf){width="2.2708333333333335in" height="0.6979166666666666in"}Plum Island

# ![](media/image2.jpeg){width="0.8020833333333334in" height="0.5625in"}Animal Disease Center

> *Research Participation Program*

**APPLICATION**

Type or print clearly and return the completed application form and
**[all]{.underline}** supporting materials to the Oak Ridge Institute
for Science and Education.

+---------+---------+--------+------------+-------------+-------------+
| **A     | Post    | Post   | Post       | Other       |             |
| pplying |         | ma     | bac        | research    |             |
| as:**   | do      | ster's | calaureate | opp         |             |
|         | ctorate |        |            | ortunities: |             |
+---------+---------+--------+------------+-------------+-------------+

+--------+-------------------+-------------------+--------------------+
| 1      |                   |                   |                    |
| .  **N |                   |                   |                    |
| ame:** |                   |                   |                    |
+--------+-------------------+-------------------+--------------------+
|        | *(First)*         | *(Middle)*        | *(Last)*           |
+--------+-------------------+-------------------+--------------------+

2.  **Citizenship:** U.S. Citizen Yes (*skip to question 3*)

No (*answer question 2a, 2b and 2c as applicable*)

  ---------------------- -------- ------------- ------------- -------------
  2a. Country of                                              
  Citizenship:                                                

  2b. Are you a Lawful                                        
  Permanent Resident?                                         
  Yes No (*skip to                                            
  question 2c*)                                               

  2c. Do you have a                                           
  visa? Yes (*provide                                         
  visa information                                            
  below*) No                                                  

  What type of visa do                          Expiration         
  you currently have?                           Date:         
  ---------------------- -------- ------------- ------------- -------------

3.  **Address and Contact Information:**

  ---------- ---------------------------- ---------- ------- ------------------------
  Address:                                                   

                                                             

  City:                                                      

  State:                                  Country:           

  Zip:                                                       

  Phone:                                  Cell                    
                                          Phone:             

  Fax:                                                       

  E-mail:                                                    
  ---------- ---------------------------- ---------- ------- ------------------------

Application 1 of 4

> Name:      

4.  Current Academic Status *(please answer either question 5a or 5b)*

> 4a. If you are currently a student:

  -------------- ------- ------- ------- -------------------------------------------------
  Degree:                                

  Expected                                    
  Graduation                             
  Date:                                  

  Academic                               
  Institution:                           

  Major field:                           
  -------------- ------- ------- ------- -------------------------------------------------

> 4b. If you are not currently a student:

  -------------- ------- ------- ------- ----------------------------------------------------
  Highest Degree                              
  Held:                                  

  Graduation                             
  Date:                                  

  Academic                               
  Institution:                           

  Major field:                           
  -------------- ------- ------- ------- ----------------------------------------------------

5.  **List members of scientific staff at the PIADC with whom you may
    have contacted regarding a future research position.**

+---+-----------------------+-------+---------------+--------------------+
|   | **Name**              | **E   |               | **Phone**          |
|   |                       | -Mail |               |                    |
|   |                       | Addr  |               |                    |
|   |                       | ess** |               |                    |
+---+-----------------------+-------+---------------+--------------------+
|   |                       |       |               |                    |
+---+-----------------------+-------+---------------+--------------------+
|   |                       |       |               |                    |
+---+-----------------------+-------+---------------+--------------------+
|   |                       |       |               |                    |
+---+-----------------------+-------+---------------+--------------------+
| 6 |                       |       |               |                    |
| . |                       |       |               |                    |
|   |                       |       |               |                    |
|   |                       |       |               |                    |
| * |                       |       |               |                    |
| * |                       |       |               |                    |
| H |                       |       |               |                    |
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| p |                       |       |               |                    |
| r |                       |       |               |                    |
| o |                       |       |               |                    |
| g |                       |       |               |                    |
| r |                       |       |               |                    |
| a |                       |       |               |                    |
| m |                       |       |               |                    |
| ? |                       |       |               |                    |
| * |                       |       |               |                    |
| * |                       |       |               |                    |
+---+-----------------------+-------+---------------+--------------------+

7.  Attach Resume or Curriculum Vitae *(MUST include the following
    information.)*

*Academic History (institution, dates, degree, major, GPA)*

*Employment Record (current employer, dates, part-time or full-time)*

*Relevant Research Experiences (include list of publications and
presentations)*

9.  **Send Application Materials and Résumé or Curriculum Vitae** *(**DO
    NOT** send duplicate applications)*

> **E-mail:**
>
> <piadc@orau.org>
>
> **By mail:**
>
> Oak Ridge Institute for Science and Education *For Overnight
> Delivery:\
> *PIADC Research Participation Program ORISE -- PIADC Program\
> P.O. Box 117, M.S. 36 1299 Bethel Valley Road
>
> Oak Ridge, TN  37831-0117 Building SC-200
>
> Oak Ridge, TN 37830
>
> **By Fax**
>
> \(865\) 576-4197

Application 2 of 4

Name:      

# Plum Island

# Animal Disease Center

*Research Participation Program*

**DEMOGRAPHIC INFORMATION**

Applicant demographic data are important in assessing the effectiveness
of our efforts to solicit applications from a diverse population. Your
submission of this information will assist us in this regard. We
appreciate your cooperation. If you decline to provide this information,
it will in no way affect consideration of your application.

**Ethnicity** *(check one only)*

Hispanic or Latino

Not Hispanic or Latino

**Race** *(check all that apply)*

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Sex:

Female

Male

Disability Statement: *(physical or mental impairment that substantially
limits one or more major life activities; for example, blindness,
deafness, or mobility impairment)*

Yes

No

Demographic Information 3 of 4

Name:      

# Plum Island

# Animal Disease Center

*Research Participation Program*

**CERTIFICATION OF ACCURACY OF INFORMATION PROVIDED**

I am aware that this program is supported by funding from the United
States Government and, therefore, is subject to Federal law regarding
false statements and fraud, particularly the criminal provisions of 18
U.S. Code Section 1001. I certify, under penalty of law, that the
submitted student application contains no false or fraudulent
representations, statements, or entries.

The U.S. Government conducts background investigations to establish that
individuals are eligible for a required security clearance. The
background investigations for national security positions are conducted
to develop information to show whether you are reliable, trustworthy, of
good conduct and character, and loyal to the United States. In addition
to filling out a form (such as the Standard Form 86 which may be viewed
at: http://www.opm.gov/forms/html/sf.asp), inquiries also may be made
about a person's adherence to security requirements, honesty and
integrity, vulnerability to exploitation or coercion, falsification,
misrepresentation, and any other behavior, activities, or associations
that tend to show the person is not reliable, trustworthy, or loyal.

**For e-mail submitted applications:**

Yes, I so certify Date certified:      

**For paper applications sent by mail or fax:**

Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date certified:      

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# Certification 4 of 4