Biotechnology 101 Sponsorship Application Form The four AAPS Biotechnology 101: Fundamentals of Biotherapeutics eLearning program sponsors have each agreed to help support educational opportunities in the pharmaceutical sciences. Their generous grant provides funding for 100 graduate and postdoctoral students towards one complimentary AAPS Biotechnology 101 elearning lecture and a one-year membership in the association. Please fill out the required information on this form. Awards are limited to 10 per school, so APPLY TODAY! Please direct any questions to Stacey May, AAPS Public Outreach Director, at MayS@aaps.org. Please briefly answer the following questions to be considered for the grant: * What AAPS Biotechnology 101 lecture are you interested in taking? * What future eLearning content would be of most interest to you? * How can an AAPS Membership serve you and your professional development? Current Personal Information * Prefix: (Select) Mr. Mrs. Ms. Dr. * Membership Status: (Select) Full-Time Graduate/Undergraduate Student Postdoctoral Fellow * Full Name: Department/Area of Study: School: * Street Address: * City: * State: (Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming * Postal Code: * Country: Phone: Cell Phone: Fax: Email Address: Highest Academic Degree: Expected Graduation Date: Institution where you received your highest degree: Permanent Personal Information Street Address: City: State: Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code: Country: Phone: Email Address: Choose an AAPS Section Choose up to 2 sections Analysis and Pharmaceutical Quality (AP) Read Overview Biotechnology (BT) Read Overview Clinical Pharmacology and Translational Research (CP) Read Overview Drug Design and Discovery (DD) Read Overview Formulation Design and Development (FD) Read Overview Manufacturing Science and Engineering (MS) Read Overview Pharmacokinetics, Pharmacodynamics and Drug Metabolism (PP) Read Overview Physical Pharmacy and Biopharmaceutics (PB) Read Overview Regulatory Sciences (RS) Read Overview To what scientific societies do you belong? Demographics (optional) This information is for statistical purposes only and will only be released as aggregate data. With which group do you most closely idenitfy? African American/Black Asian/Pacific Islander Caucasian/White Hispanic Native American Gender Male Female Birth Date