Research Exchange Application

Research Exchange Application

First Name*

Last Name*

Email*

Phone Number*

Current Institution*

Select or enter value

Current Department*

Doctoral Student or Postdoc?*

Doctoral Student

Postdoc

If a Doctoral student, year in PhD program?

Please offer only a number.

If a Doctoral student, have you reached candidacy?

i.e. passed your qualifying exam

Yes

For both Doctoral and Postdocs, degree and approximate completion date?*

For example: Computer Science, Spring 2016 OR: PhD completed Spring 2014 for Postdocs

Please Upload TWO documents: CV and Research Statement*

1. Curriculum Vitae (CV) 2. Provide a current research statement (250 words) **Please offer both documents in pdf format only.

Drag and drop files here or

Current Faculty Mentor*

Potential Visit Dates (mm/dd/yyyy - mm/dd/yyyy)*

Please provide potential date(s) and/or a general time frame for your visit: We recommend scheduling your visit 3-6 months from your application submission. Generally, visits must last at least 3 days and no more than 7 days. If your intended visit is outside of this range please explain so we may consider your request.

Proposed Faculty Mentor at Campus (First Choice)

Campus 1st Choice*

Select or enter value

Faculty Member Name*

Have You Been in Contact with this Faculty Member?*

Yes

Proposed Faculty Mentor at Campus (Second Choice)

Campus 2nd Choice*

Select or enter value

Faculty Member Name

Have You Been in Contact with this Faculty Member?*

Yes

Proposed Faculty Mentor at Campus (Third Choice)

Campus 3rd Choice

Select or enter value

Faculty Member Name

Have You Been in Contact with this Faculty Member?

Yes

Proposed Faculty Mentor at Campus (Fourth Choice)

Campus 4th Choice

Select or enter value

Faculty Member Name

Have You Been in Contact with this Faculty Member?

Yes

What are your top three goals for this visit? (ie network, establish new collaboration, give/hear research presentations, learn new technique, etc.)*

Why are you interested in this opportunity? Please indicate also why at this time in the stage of your doctoral/postdoctoral training.*

Why do you want to establish this mentoring relationship?*

US Citizen*

*As defined by NSF AGEP program guidelines the term "[US] national" designates a native resident of a commonwealth or jurisdiction of the United States, such as American Samoa, Guam, the Commonwealth of Puerto Rico, the United States Virgin Islands, or the Commonwealth of the Northern Mariana Islands.

Select or enter value

What is Your Race/Ethnicity? Please list all that apply to your identity.*

Gender*

Disclaimer*

To enable the partner universities to conduct RUA’s work, we will be sharing participant data between authorized staff at the RUA member universities. By participating in RUA programs, the participant agrees to this sharing of data. As required by the Family Educational Rights and Privacy Act, 20 U.S.C. 1232g, and its implementing regulations, 34 C.F.R. pt. 99, this information will be used only for the purpose of implementing and evaluating RUA and its activities, which are intended to improve instruction by generating knowledge and insights regarding practices that contribute to the advancement of early career scholars (both doctorate students and postdoctoral fellows) into academic careers. RUA’s cross-institutional data sharing agreement is available on request.

Please check the box below to acknowledge that you have read the above disclaimer.

Join the RUA Alumni Network (Optional)

Upon acceptance of your application for the Research Exchange, you are invited to join the RUA Alumni Network that seeks to bring together alumni from all of our AGEP programs and iterations in one central RUA community. The RUA Alumni Network consists of two components RUA alumni email listserv and alumni directory. The purpose of the RUA Alumni Network is to encourage community engagement and professional networking. You can read more about the RUA Alumni Network on the RUA website, click this link to be redirected.

Please check the box below if you would like to opt in now. Reminder that access to the alumni network is contingent on your participation in the Research Exchange and/or other RUA activities. This will not be your only opportunity to opt in. RUA will send you multiple invitations to join.

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