The New York Academy of Medicine
Center for the History of Medicine and Public Health

Paul Klemperer Fellowship in the History of Medicine
Audrey and William H. Helfand Fellowship in the History of Medicine and Public Health

Application for 2019
Deadline: Friday, August 24, 2018

1. Short title of your project (30 words or less): _______________________________

________________________________________________________________________

2. Applicant’s name: _______________________________________________
			(last)				(first)

3. Address/Affiliation:_____________________________________________________
(title)
_____________________________________________________ (department, if applicable)
______________________________________________________
(institution, if applicable)
______________________________________________________
(street)
______________________________________________________
(city, state or province, ZIP or postal code, country)

4. Phone numbers: 	________________	_________________	______________
		 	(work)			(home)			(mobile)

5. E-mail address:	__________________________________________________

6. References: Provide contact information for two people who will be sending letters of recommendation:

	A. 	___________________________________________________________
		(name)
		____________________________________________________________
		(affiliation)			
		__________________	__________________
		(phone)				(email)

	B. 	____________________________________________________________
		(name)
		____________________________________________________________
		(affiliation)			
		__________________	__________________
		(phone)				(email)

7. Abstract of your project proposal (150 words or less):

8. Curriculum Vitae: attach your current CV; make sure to include the following:
a. Educational history: include any programs in which you are currently enrolled, as well as post-doctoral experience. Include the institutions, the fields of study, degrees received (if any), and the dates of enrollment. 
b. Research and professional experience: include all work experience that you consider relevant to this fellowship.
c. Professional and academic honors 
d. Personal Bibliography: include journal articles, book chapters, books or other publications, and theses and dissertations.

9. Project proposal: Attach a description, in no more than two thousand words, of the project for which you are seeking this fellowship. Please specify how this project will fit in with your broader professional objectives. As part of the proposal, you must provide detailed information about the Academy Library resources you intend to consult for your project.  This may include information about uniquely held materials or about significant holdings that support your research.  You may discuss those resources in the proposal or add a bibliography at the end.

13. Agreement and signature: read and sign.

If awarded a fellowship, I agree to present a seminar on my work at The New York Academy of Medicine, to write a blog post, and to submit a final report on my project upon completion of the fellowship.
		
I certify that all information given in this application is true and complete to the best of my knowledge.

_______________________________
(applicant’s signature)

________________________________
		(date)