UT - College of Graduate Studies

College of Graduate Studies - Summer Undergraduate Research Fellowship Application

Personal Data

Legal Name

Last Name
First Name
Middle Name

Marital Status
Married
Single

Sex
Male
Female

Date of Birth

Month Day Year(xxxx)

Place of Birth

City
State
Country
Country of Citizenship

Other names under which you registered in any educational institution, including high school.

Last Name
First Name
Middle Name

Permanent Address :

Street		City and State
Zip Code		County (if Ohio)
Permanent Phone		E-Mail Address
Country

Present Address: Same as Permanent Address

Street		City and State
Zip Code		County (if Ohio)
Permanent Phone		E-Mail Address
Country

Ethnicity

White, not of Hispanic Origin
American Indian/Alaskan Native
Asian or Pacific Islander
Black, not of Hispanic Origin
Other Hispanic American (Central/South American)
Other

Previous Education

High School City and State

From:	Month	Yr.(xxxx)	To:	Month	Yr.(xxxx)	Graduation:	Month	Yr.(xxxx)

Complete for all universities (including Medical University of Ohio), colleges, schools of nursing, technical schools, other post-high school educational programs you have attended. Have official transcripts forwarded from each school.

1.College/University/School

City and State

Attended:
From: Month		Year
To: Month		Year


Major
Name of Degree

Degree/Certificate Completed
Month
Year

2.College/University/School

City and State

Attended:
From: Month		Year
To: Month		Year


Major
Name of Degree

Degree/Certificate Completed
Month
Year

3.College/University/School

City and State

Attended:
From: Month		Year
To: Month		Year


Major
Name of Degree

Degree/Certificate Completed
Month
Year

4.College/University/School

City and State

Attended:
From: Month		Year
To: Month		Year


Major
Name of Degree

Degree/Certificate Completed
Month
Year

Have you ever been denied admission or employment, suspended, or dismissed for disciplinary reason by any college, university, professional, or post-high school educational program or employer?
No Yes If yes, attach a statement of explanation below

Miscellaneous Information

Dates of Availability (mm/dd/yyyy)
From:
To:
(Program is three months in duration)

Research Program of Interest

Cancer Biology
Cardiovascular and Metabolic Diseases
Infection, Immunity, and Transplantation
Neuroscience and Neurological Disorders

Relative's Data

Contact in Case of Emergency:
Spouse Parent Legal Guardian Nearest Relative Other

Person checked above:

First Name
Middle Name
Last Name
Street and Number
City, State, Zip Code
Telephone

References

Please list the names, addresses and phone numbers of three references we may contact. In addition to these references, applicants must also submit 2 letters of recommendation.
1.	2.	3.
Why are you applying to this fellowship? In your response please provide a description of 1) your career goals, and 2) your expectations of the Summer Research Fellowship experience, and 3) any previous research experience.

Academic Record

List all science courses taken and grade received.
College Name/Location	Academic Year	Term	Course Name	Course Number	Credit Hours	Grade

Certification
You agree to this statement by pressing the submit button upon completing this application. I affirm that the information I have provided on this application form and all other admission application materials is complete, accurate, and true to the best of my knowledge. I have authorized each college or university I have attended to release academic and personal information as related to this admission application upon request by the Medical University of Ohio. I agree to submit other materials that are required for this admission application. I understand that furnishing false information on any part of this admission application may result in cancellation of admission or registration, or both.

IMPORTANT: If you would like to print a copy of this application for your records, you must do so before pressing the submit button, or all filled in information will be lost.

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