[Eligibility for the GRIP Program]{.underline}

**GLOBAL RESEARCH INITIATIVE PROGRAM FOR NEW FOREIGN INVESTIGATORS,
"**[GRIP-Behavioral and Social Sciences
"PAR-07-328"](http://grants.nih.gov/grants/guide/pa-files/PAR-07-328.html)
and [GRIP-Basic and Biomedical Sciences is
"PAR-07-239"](http://grants.nih.gov/grants/guide/pa-files/PAR-07-239.html).

To verify eligibility for this program, please fill out the following
form and return to:

Dr. Aron Primack

\*Email: <primacka@mail.nih.gov>

Fax: (301) 402-0779

Post: Fogarty International Center, National Institutes of Health, 31
Center Drive, Room B2C39, Bethesda, MD 20892-2220 USA

*\*Submission by email is preferred.*

Thank you!

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  Family Name:      

  First Name:      

  Email Address:      

  Home Country:      

  Home Institution:      
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Information pertaining to training in the US:

A.  Extramural, under FIC-supported training grant using the D43
    mechanism:

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  Grant Number: D43-     

  Name of Fogarty Program:      

  University/Institute Affiliation:      

  Name of PI on Training Grant:      

  Name of Mentor (if different from PI):      

  Mentor Telephone:      

  Mentor Email:      

  Exact Dates of Training *(Month/Year -- Month/Year):*      
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B.  Intramural, at an Institute of the NIH:

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  NIH Institute and Division:      

  Name of Mentor:      

  Mentor Telephone:      

  Mentor Email:      

  Exact Dates of Training *(Month/Year -- Month/Year):*      
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If either extramural or intramural training was for a period of less
than one year, please provide information on the second year of mentored
research:

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  Name of Mentor:      

  University/Institute Affiliation:      

  Mentor Telephone:      

  Mentor Email:      

  Exact Dates of Training *(Month/Year -- Month/Year):*      
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If through another mechanism such as NIDA INVEST or Humphrey fellow,
HFSP, or F05 program:

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  Name of Mentor:      

  University/Institute Affiliation:      

  Mentor Telephone:      

  Mentor Email:      

  Exact Dates of Training *(Month/Year -- Month/Year):*      
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Are you currently a student under any degree program? Yes No

If "YES," please include the following:

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  Type of Degree:      

  Institution:      

  Name of Advisor or Chief Administrator:      

  Contact Info for Advisor/Administrator:      

  Anticipated Date of Receipt of Degree *(Month/Year):*      
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