Fellowship Application Harvey L. and Maud C. Sorensen Foundation Postdoctoral Research Fellowship in Child & Adolescent Psychiatry Name* First Middle Last Preferred Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell phone with area code*Work phone with area code PERSONAL e-mail address* Where did you go to college? Name of institution & location* What year did you graduate from college?* What is your undergraduate degree (i.e., B.A., B.S.) and in what field?* Where did you go to medical school? Name of institution and location* What year did you graduate from medical school?* If you have a second graduate degree, or a non-medical graduate degree, list the institution and location here. If you have a second graduate degree, or a non-medical graduate degree, indicate the year that you graduated If you have a second graduate degree, or a non-medical graduate degree, indicate the degree and field of study. Where are you doing your residency or where did you complete your residency? (Name of institution and location)* In what year of your residency training are you? If you have completed your residency, indicate the year of completion.* Title or very brief description of proposed research:*Name of medical school where you will conduct this research:* Funding Requested:* 1 Year 2 Years 3 Years Name, title, mailing AND E-mail addresses of Principal Investigator(s)/Mentor(s)*Fellowship awards may be activated between July 1 and September 30, 2023. Date you would activate the fellowship?* MM slash DD slash YYYY