K Award Workshops
General KNOW YOUR K Session
Registration Form
Date: Wednesday, March 3, 2010
Time: 8:30 - 10:30 AM
Room: S120 Thomas E. Starzl Biomedical Science Tower
*
First Name
*
Last Name
*
Primary School
Select one from list:
Dental Medicine
Health & Rehab. Sciences
Medicine
Nursing
Pharmacy
Public Health
Other School
Does Not Apply
If Other,
School Name:
Department
Division
*
Primary Position Title
Select one from list:
Faculty:Professor
Faculty:Associate Professor
Faculty:Research Associate Professor
Faculty:Assistant Professor
Faculty:Research Assistant Professor
Faculty:Instructor
Faculty:Visiting
Faculty:Other
Research Associate
Fellow:Clinical
Fellow:Postdoctoral
Fellow:Other
Resident
Staff
Student:MD/PhD
Student:Graduate
Student:Medical
Student:Undergraduate
Student:Other
Other
If Other,
Title:
Phone
*
Email Address
Campus Address:
*
How were you informed of this program?
Email Flyer
Print Flyer
OACD Website
Poster
Word of Mouth
Other
Questions?
Contact the Office of Academic Career Development
412-648-8486 or oacd@hs.pitt.edu
Print screen for your records before submitting.
*
Indicates Response Required