Name:
IC(s):	- Select Institute or Center - CBER CC CIT NCI/CCR NCI/DCEG NCCAM NEI NGHRI NHLBI NIA NIAAA NIAID NIAMS NICHD NIDA NIDCD NIDDK NIDR NIEHS NIMH NINDS NINR NLM/LISTER HILL NLM/NCBI OD
Lab/Branch:
Present Position/Institution:
Proposed Appointment Mechanism :*

*e.g., Title 42 (including Visiting Scientists), Expert, IPA, Contract-supported, etc.

Please submit in the following order (original plus 15 copies)

1. Recommending memorandum describing the research project for the scholar and the trans-institute nature of the appointment, from either:
   1. IC Director, ___________________________, or
   2. Special Interest Group, ______________________, Chair ________________
2. The memorandum should address the review criteria listed below.
   1. CV and bibliography. (Check the five most important publications.)
   2. Supporting documents, such as letter(s) of recommendation.
   3. Appointment Information
      1. Date(s) of appointment ___________ to ____________
      2. NIH contribution toward stipend $ ________________
      3. Special Interest Group(s) to be affiliated with ________________________

For Panel Use - Review Criteria to be Applied by the Panel

• Scientific and intellectual excellence
• Professional stature in nominee's field of expertise
• Capacity to interact with the NIH scientific community, other Fogarty Scholars, and other scientific and professional groups, including colleagues at the home institution after returning from the residence at the NIH.
• Evidence of planned interaction with one or more Special Interest Groups (a.k.a., Inter-Institute Groups)