AMERICAN PHYSIOLOGICAL SOCIETY
9650 Rockville Pike
Bethesda, MD 20814 USA
PERKINS MEMORIAL FELLOWSHIP AWARD
APPLICATION - VISITING SCIENTIST
Please submit a formal curriculum vitae with this application.
Surname__________________________________
First_____________________________________
Affiliation_________________________________________________________________________
Address_____________________________________________________________________________
City/State__________________________________________________________________________
Zip____________________
Country_____________________________________________________
Spouse's name__________________________________________
Birthday____________________
Children___________________________________________________
Age_____________________
___________________________________________________ Age_____________________
___________________________________________________ Age_____________________
Duration of visit: From____________________________
To______________________________
Has your family previously visited the United States? If so, please
indicate purpose and length of stay
__________________________________________________________________
____________________________________________________________________________________
List ALL sources and amount of funds available including spouse's income for
this visit (exclusive of the Perkins Fund)
_______________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you have, or can you secure private resources that would enable you to
bring your family?
_____________________________________________________________________________
If you do not receive a Perkins award, will your family accompany
you?______________
____________________________________________________________________________________
Language proficiencies of applicant and family
members______________________________
____________________________________________________________________________________
Will children attend local schools? If so what are your plans to help
them with language?
____________________________________________________________________________________
List outside interests of applicant and
spouse______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you have friends or relatives in the host country? If so, where do
they live?
____________________________________________________________________________________
Do you plan to travel during vacations? If so,
where?_______________________________
____________________________________________________________________________________
Some questions may be answered in more detail than others. You are
encouraged to include other information which might assist the Perkins
Committee in coming to a decision.
____________________________
____________________________________________________
Date
Signature
(Applications are due April 15 and October 15 with notification of
applicants June 15 and December 15, respectively). For scientific visits
beginning between January 1 and June 30, the application is due on October
15 the year before with notification by December 15. For scientific visits
beginning between July 1 and December 31, the application is due on April 15
of the same year with notification by June 15.
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