Academic Fellowship Form Upon completion, return to Office of Human Resources, 216 Bray Hall
Fellow’s Last Name ____________________________________ First Name________________________ Middle______
_________________________________________________________________________________________
Mailing Address—Street, City, State, Zip
Check One:
Dr. ___ Ms. ___
Mrs. ___ Mr. ___
Miss ___
Fellowship Type:
_____ Faculty _____ Undergraduate _____ Graduate _____ Postdoctoral
Award Begin Date: ____________________________
Award End Date: _____________________________
Award Amount: $_____________________________
Project Director Approval (required for all)
Signature:________________________________________________________ Print Name: _______________________________________________________ Date: ________________
Department: ___________________________________________ Phone #: __________________________________ Email:__________________________________________________
Department Chair/Director Approval - Required for all PI & CO PI appointments and required for FNRM and Paper Bioprocess Engineering
Signature: ____________________________________________________________ Date:___________________
Local Address: ________________________________________________________________
Permanent Address: _____________________________________________________________
Home/Cell Phone: ________________ Work Phone: _________________ Date of Birth: ________________
Email: _________________________________ Social Security # ___________________________________
FELLOW INFORMATION - FELLOW TO COMPLETE
Nationality:
______ US Citizen
______ Non-Citizen in US on Visa
Visa Type: _________________________
______ Permanent Resident
Education:
Level Completed: ________________________
Degree Expected: ________________________
Date Degree Expected: ____________________
Ethnic Origin: (select all that apply—see back page for definitions)
____ American Indian or Alaska Native ____ Hispanic or Latino ____ Asian
____ Native Hawaiian or Other Pacific Islander ____ Black or African American ____ White
I acknowledge that no services are required of me in consideration of the stipend provided by this fellowship award.
Intellectual Property Assignment I have read The State University of New York’s Patents, Inventions and Copyright Policy (“SUNY Policy”) and RFSUNY’s Intellectual Property
Policy (“RF Policy”). I agree to abide by the SUNY Policy and the RF Policy, and by any additional terms and conditions imposed by any sponsor from which I accept support through
RFSUNY, including but not limited to the Patent and Trademark Amendments Act (i.e., Bayh-Dole Act) and its implementing regulations found in 37 CFR 401. I will promptly
disclose to RFSUNY or its designee any Intellectual Property (as defined in the SUNY Policy) subject to the SUNY Policy or sponsor requirements, and will cooperate with RFSUNY,
the sponsor, and the State University of New York, and execute any such documents as may be necessary to protect the subject Intellectual Property. I understand that the prompt
disclosure of Intellectual Property developed within the scope of my employment is required to enable its protection prior to U.S. or foreign statutory bars and to establish the
government’s rights, where applicable. I hereby assign to RFSUNY all rights in Intellectual Property subject to the SUNY Policy, and will execute any documents required to effectuate
such assignment to or as directed by RFSUNY.
As an Equal Opportunity/Affirmative Action Employer, the RFSUNY will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including
pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, physical and
mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled,
special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. The RFSUNY will
not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another
employee or applicant.
Fellowship Signature: _____________________________________________________________________ Date: ____________________________________________________
Declaration Authorization
PROJECT DIRECTOR TO COMPLETE
Office of Research Programs: ________________________________________________ Date:______________
Operations Manager: ________________________________________________ Date:______________
Date Reviewed Request Submitted to HR: ______________________ Visa Share File Done: _________________
Work Author
ization Expiration Date: __________________________ Student Status Checked: ______________
Employee # ____________________________
Visa Type: _____________________________
Date Input by: __________________________
LD: __________________________
Copies: PR ___________ TK ___________ Date: ______________________
Special Notes: _________________________________________________________________________________________________________________________________
Revised 11/30/17
Project Task Award Organization Expenditure Type LD Start Date LD End Date %
For Office Use Only
Signatures
