# 4^th^ Annual ADVANCED TRAINING INSTITUTE ON HEALTH BEHAVIOR THEORY

## JULY 6-13, 2008

**APPLICATION**

***Applications must be received by February 22, 2008.***

Please type or print the information listed below.

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  Name                    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     

  Professional Title      \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     

  Department/Division     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     

  University or           \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     
  Institution                                                                                                                                                  

  Academic/Professional   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     
  Degree(s), Field(s),                                                                                                                                         
  and Year(s) Obtained                                                                                                                                         

  Gender (optional)       \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                                                                   Ethnic Background \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
                                                                                                                                             (optional)        
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##### Contact Information

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  Street Address      \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                             

  City, State, Zip    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                             
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  Telephone           \_\_\_\_\_\_\_\_\_\_\_\_                                                                                           Fax   \_\_\_\_\_\_\_\_\_\_\_\_   E-mail   \_\_\_\_\_\_\_\_\_\_\_\_\_
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##### Alternate Contact Information

(Only provide alternate contact information if for some period prior to
the beginning of the institute your current contact information cannot
be used to reach you.)

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  Starting Date       \_\_\_\_\_\_\_\_\_\_\_\_ through July 6, 2008                                                                                                                

  Street Address      \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                             

  City, State, Zip    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                             
  Code                                                                                                                                                                             

  Telephone           \_\_\_\_\_\_\_\_\_\_\_\_                                                                                           Fax   \_\_\_\_\_\_\_\_\_\_\_\_   E-mail   \_\_\_\_\_\_\_\_\_\_\_\_\_
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How did you learn about this training institute? (i.e., through which
organization? Through a list serve, newsletter, etc.?)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### Supporting Materials

**Please enclose the following with your submitted application, in the
following order:**

-   A letter of recommendation from a person who is familiar with you
    and your research (maximum 2 pages). This letter can accompany your
    application or be sent separately.

-   A personal statement. It should: 1) describe your research interests
    and goals; 2) explain your interest in the training institute,
    including what you hope to get out of it; and 3) discuss how your
    future research would benefit from participating in the training
    institute (maximum 500 words). Try to be as specific as possible.

-   Your curriculum vitae

-   A list of graduate courses that you have completed in the behavioral
    sciences and statistics (Please note: You must have completed at
    least one graduate level course in the behavioral sciences and one
    graduate level course in statistics to be considered for acceptance,
    but list all your courses in these areas.) If a course title does
    not clearly reveal its behavioral science content, feel free to add
    a sentence explaining what it covered.

**Applications must be *received* by February 22, 2008. Please mail five
(5) collated copies of this application and the supporting materials
to:**

+-----------------------------------+-----------------------------------+
| Dr. Barbara Curbow                | For questions about the           |
|                                   | application                       |
| Attn: ATI on Health Behavior      |                                   |
| Theory                            | process, please contact Dr.       |
|                                   | Curbow at:                        |
| University of Florida             |                                   |
|                                   | Phone: 352-273-6745               |
| Dept. of Behavioral Science &     |                                   |
| Community Health                  | E-mail: <bcurbow@phhp.ufl.edu>    |
|                                   |                                   |
| PO Box 100175                     |                                   |
|                                   |                                   |
| Gainesville, FL 32610-0175        |                                   |
+-----------------------------------+-----------------------------------+

#### Application Checklist 

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  \_\_\_\_\_   5 copies of my application form                                 

  \_\_\_\_\_   5 copies of my letter of recommendation (maximum 2 pages)       

  \_\_\_\_\_   5 copies of my personal statement (maximum 500 words)           

  \_\_\_\_\_   5 copies of my curriculum vitae                                 

  \_\_\_\_\_   5 copies of my list of graduate courses in the behavioral       
               sciences and statistics                                         

                                                                               
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*I understand that the training institute can accommodate only a limited
number of applicants and that an applicant who fails to attend after
acceptance denies another worthy applicant the opportunity to
participate. Therefore, I assure the National Cancer Institute and the
Office of Behavioral and Social Science Research that, if accepted, I
will participate in the full program of the training institute from July
6 to July 13, 2008*

*In addition, I assure the National Cancer Institute and the Office of
Behavioral and Social Science Research that I am a U.S. citizen or a
non-citizen with permanent residential status.*

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