AMERICAN FEDERATION FOR MEDICAL RESEARCH FOUNDATION HENRY CHRISTIAN AWARDS APPLICATION FORM These awards were begun in 1990 to honor the founder of AFMR, Dr. Henry Christian. In 2015, the awards will be given to the presenters and first authors of the most outstanding abstracts submitted in each abstract category for the 2015 AFMR Regional Meetings. Presenters at the Western Regional Meeting in Carmel, the Southern Regional Meeting in New Orleans, the Combined Midwestern Meeting in Chicago and the Eastern Regional Meeting in Washington, DC who meet the requisite criteria are eligible. Award winners will be required to present their work via poster at the 2015 AFMR Eastern Regional Annual Meeting in Washington, DC and will also be recognized at the Annual AFMR Henry Christian and Awards Dinner on Wednesday evening, April 15, 2015. Candidates must be physicians who are post-M.D. trainees, including residents, clinical fellows, physicians pursuing graduate degrees, PhDs and other post-doctoral fellows. Awardees will receive a Certificate of Excellence and a $1,250 honorarium. ALL MATERIALS MUST BE RECEIVED BY JANUARY 30, 2015 FULL NAME DEGREES INSTITUTION MAILING ADDRESS CITY STATE ZIP TELEPHONE FAX E-MAIL MENTOR’S NAME TITLE INSTITUTION I am a post-M.D. trainee, select type: Resident Clinical Fellow Physician pursuing graduate degree COUNTRY PhD Other Post-Doctoral Fellow: ____________ I am an AFMR Member in good standing. I will pay my AFMR Membership dues by credit card online: afmr.org I wish to become an AFMR Member and will apply online: afmr.org/membership.cgi I wish to become an AFMR Member. Membership application form and check enclosed. $225.00 U.S (Active Member) enclosed $90.00 U.S (Associate Members) enclosed Please make check payable to the American Federation for Medical Research All materials must be submitted by January 30, 2015, in one single PDF: Complete application form Copy of abstract submitted to an AFMR Regional Meeting Note: If applying with more than one abstract, please submit separate, complete applications. Do not include two abstracts in one single application packet. Copy of CV Submit application via email to [email protected] with subject line: applicant name, Henry Christian Awards Application. For questions, contact the administrative office at (978) 927-8330. Incomplete or late applications will be returned to the applicant without review.