ACMG Foundation Next Generation Clinical Genetics Fellowship

Joint/Individual Institutional Application

2020-2022 Fellowship Award

APPLICATION CHECKLIST

Individuals who have identified a training program that is willing to accept them if they can find support for their training can apply jointly with their planned institution/mentor. Institutions may also apply for training awards that will be aligned with specific trainees and approved by ACMGF prior to the initiation of training. When completing the application, please submit the following by July 19, 2019:

OUTLINE OF REQUIREMENTS FOR APPLICATIONS

• Applicant is limited to five pages of application; Applications must be completed in 1.5 spaced; Times New Roman; Font Size 12 point. The five pages do not include references.
• Please do not send additional materials, attachments or appendices other than those requested by ACMG Foundation.
• The five-page outline should be sufficient to fully describe your project.
• Include a paragraph on what applicant is exposed to in his/her position.
• Outline should have details of what the Fellowship will entail, to include details of the research design and method.

SUBMISSION INSTRUCTIONS:

Please upload supporting documents on the last page of the application. If you have any questions please contact:

ACMG Foundation

Janae Collins

Email: jcollins@acmg.net

Phone: (240) 204-9865

7101 Wisconsin Ave, Suite 1101, Bethesda, MD 20814/ Phone 301-718-9603/ Fax 301-718-9604/ www.acmgfoundation.org

TRAINEE APPLICATION (If applying jointly)

INSTITUTION APPLICATION (REQUIRED)

ACMG Foundation Next Generation Fellowship and Residency Award Application

APPLICATION STATEMENTS

All applicants are required to agree to the following statements:

I hereby apply to the ACMG Foundation for Genetic and Genomic Medicine (“ACMGF”) for consideration of my application for the ACMGF Clinical Genetics Residency Training programPfizer (the “Award”). I agree to disqualification from consideration, to denial of the Award, and to forfeiture and redelivery of any funds granted to me pursuant to the Award in the event that any of the statements or answers made by me in this application are false or in the event that I violate any of the rules or regulations governing the Award Program. I authorize ACMGF to make whatever inquiries and investigations it deems necessary to verify my credentials and professional standing.

I have read and agreed to the conditions set forth in the Award Agreement as evidenced by my execution of the Award Agreement which is included in this Application.

I have read the application announcement and if selected as an Awardee, agree to the terms of the award program.

I hereby agree to hold ACMGF, the American College of Medical Genetics and Genomics, Pfizer, Inc., Shire Pharmaceuticals, and their respective officers, directors, members, owners, employees, and agents, harmless from any complaint, claim, or damage arising out of any action or omission by any of them in connection with this application; the application process, any award granted to me by ACMGF; the failure to grant me any award; or any demand for forfeiture or redelivery of funds issued pursuant to an award. I understand that the decision as to whether I qualify for the ACMGF Clinical Genetics Residency Training program rests solely and exclusively with ACMGF and that the decision of ACMGF is final.

I HAVE READ AND UNDERSTAND THESE STATEMENTS AND I INTEND TO BE LEGALLY BOUND BY THEM.

NOTE: Award application MUST be signed by both Trainee-Applicant and Institution. Unsigned applications will be considered invalid.

TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE TERMS OF THE ATTACHED AWARD AGREEMENT IF THE ASSISTANCE IS AWARDED.

ACMG Foundation Next Generation Fellowship and Residency

Award Application

Project Assurances