Today's Date:

Wright State UID:

Name:

Local Address:

City, State & Zip:

Local Phone:

E-mail:

Permanent Address:
(if different from above)

City, State & Zip:

Permanent Phone:

Undergraduate Instititution(s):

Year in School: First-year:   Sophomore:   Junior:    Senior:

Major:

Expected Graduation Date:

GPA (overall): GRE score:

Date of test:

Gender: Female:   Male:
Last four digits of your Social Security Number:

Are you a U.S. citizen?: Yes: No:
Are you a permanent resident?: Yes: No:

Please indicate the group(s) in which you would include yourself (check all that apply):

African American/Black
Hispanic
Hawaiian/Pacific Islander
Native American/Alaskan Native
Other (Please specify):

Are you disabled?: Yes: No:

What is the highest level of education attained by your parents or guardians?

Mother/Guardian:

Father/Guardian:

Are you from a disadvantaged background?: Yes: No:

If yes, please describe your disadvantaged status:

Please provide a response to each of the following questions. Your response may not exceed 300 words per question.

1. What Person or event has been most influential in the development of your science career? (You should describe a person or situation that propelled you toward your career path in science or research.)

2. Discuss your specific interest in pursuing a career in biomedical, behavioral or social science health-related research and your academic and career goals. Describe how the BioSTAR program would help you attain your goals, including the non-financial benefits you may attain from the program.

3. In responding to the following questions be sure to only include those activities and awards that are relevant to your interest in science and biomedical research.

a. Describe extracurricular activities in which you have participated in the past or are participating in currently. (For example-science fairs, science clubs, internships, community service, hobbies). Describe the specific role you played in the activities.

b. List special recognitions, scholastic awards and honors, and any scholarships you have received. Include a short narrative to help us understand the award, scholarship, or recognition.

c. Describe any activities, whether voluntary or paid positions, that demonstrate involvement with and/or commitment to biomedical, behavioral or social science health-related research which you participated in during the school year or summer. If you engage in research, describe the specific role you played in the research project.

4. How would you evaluate and describe your aptitude in relation to the characteristics listed below? In responding, give specific examples of science-related projects which demonstrate your aptitude in the following areas. Avoid responses "I am very curious" or "I have much initiative." Carefully evaluate and include specific and relevant examples.

a. Initiative

b. Work habits

c. Curiosity

d. Creativity in problem-solving

e. Ability to work as member of a team

f. Leadership skills (include elected or other positions you have held or projects you have initiated)

Instructions: All of the following material MUST be submitted before an application will be considered.

Applicant Information Form: As submitted above

Transcript(s): Official copies of all undergraduate transcripts (including courses in progress)

Faculty Recommendations: Two completed reference forms from academic faculty. (The reference form is included with the downloadable application. Provide the names and e-mail addresses of your references below).

1. Name:

E-mail:

2. Name:

E-mail: