1 Application Form for APA Division 39 Graduate Student Scholar Award Completed applications must be e-mailed by January 10,

2014 to the committee chair, Jeremy D. Safran, Ph.D., at Division39GraduateScholars@gmail.com Committee Members: Jeremy Safran Lewis Aron Elliot Jurist Bart Magee J. Christopher Muran Erica Gardner- Schuster, Administrator Please complete this application form using Microsoft Word and e-mail it along with a copy of your curriculum vitae as attachments. Please type application in the subject line of the e-mail. Since the application form will be filled out electronically, you can use as much space for your answers as you need. Name of Applicant: Email: Address: Degree: Date of Birth: Where are you currently attending Graduate School? Gender: Date: Phone:

What year of the program are you in?

Please indicate which of the following degrees you are currently studying for:

Ph.D. Clinical Psychology: ___ M.A. Clinical Psychology: ___ Psy.D. Clinical Psychology:___ Other (please elaborate): ____ What is your current GPA in graduate school? Please list any graduate level coursework you have completed that is particularly relevant to your interests in the Division 39 Scholar Award: If you are currently conducting (or have completed) research relevant to your M.A. thesis or Ph.D. dissertation, please describe briefly (e.g. 200-350 words) : Please list any publications or poster presentations:

If you are currently involved (or have been involved) in any activities (e.g., study groups, reading groups, workshops, conferences) relevant to your application for the Division 39 Scholar Award, please list (and describe if relevant):

Are there any specific theoretical, clinical or research interests you have that might be relevant to your application? Where did you complete your undergraduate education? What year did you complete your undergraduate degree? What was your major at the undergraduate level?

3 Please list any coursework you took at the undergraduate level relevant to your interests in the Division 39 Graduate Scholar Award (relevant coursework can be in areas outside of psychology (e.g., literature, feminist studies, humanities, philosophy): Please list the names, contact information, positions and institutional affiliations for the 2 individuals who are submitting letters of reference on your behalf. All references must be received by the committee by January 10, 2014 at the latest. Letters should be e-mailed by your referees directly to the committee at Division39GraduateScholars@gmail.com.

Reference 1: Contact information: Position: Institutional Affiliation: Reference 2: Contact information: Position: Institutional Affiliation:

*Please write a short essay (maximum 2 pages) outlining why you are interested in the Division 39 Graduate Student Scholar Award and how your are hoping it might be relevant to your future professional plans: