Wufoo
Funding Search Request Form
Please complete the following form to request assistance in identifying sources of funding for your research project. This form will go directly to Stacie Mendoza, Program Director, who will contact you once your form is received to set up an appointment.
Please note:
This service is only available to University of Maryland, Baltimore faculty and postdoctoral fellows.
Any questions or concerns, please contact Stacie Mendoza at
smendoza@som.umaryland.edu
or call 410-706-5434.
Contact Information
Name
*
First
Last
Department
*
Academic Title
*
Email
*
Primary Contact Number
*
###
-
###
-
####
Alternate Contact Number
###
-
###
-
####
Degree(s)
Please also include the
date
when degree(s) were earned and at which
institution
.
Degrees
Citizenship
Are you a U.S. Citizen?
*
Yes
No
If you are not a U.S. citizen, please describe your status:
Of which countries are you a citizen or permanent resident?
More Information
How many years have you been in your current academic position?
*
Maximum of
2
digits.
Currently Used:
0
digits.
In layman’s terms, briefly explain your field of interest/research question/subject
*
Which of the following funding types interest you? (Check All That Apply)
*
Training, Scholarship or Fellowship
Postdoctoral Award
Career Development Award
Research Grant
Other (explain below)
Other funding types that interest you:
Is there a particular funding agency that you would like us to investigate?
Which societies or associations do you belong to? (Do not use acronyms)
If funding agencies for a particular disease would be appropriate for your research, please specify which diseases (i.e. diabetes, Alzheimer’s cancer, etc.)
Are you currently receiving research funding? If yes, list title(s) of grant(s), date(s) and funding agency. If not, type No
*
Have you been awarded any research funding that have expired? If yes, list title(s) of grant(s), date(s) and funding agency. If not, type No.
*
Do you have a mentor?
*
Yes
No
Name of Mentor
First
Last
Optional
You do not have to complete the following information; however, by doing so, you will help us to determine if you are eligible for certain funding mechanisms targeted to underrepresented minority scientists.
Ethnicity
African-American
Hispanic
Native American
First generation college graduate
Other, please explain
Other ethnicity
Gender
Male
Female
Attach your CV (not required)
Availability
Please identify at least 3 days/times when you would be available to meet to discuss funding sources identified for you between Tuesday thru Friday (8am – 2pm). If you are not available during these days/times, please specify your availability below.
Day/Time Available - 1
Day/Time Available - 2
Day/Time Available - 3
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