Online Application Form
Instructions: Use this form to apply online for the Short-Term
Training Program to Increase Diversity in Health-Related Research (STREAMS)
that runs from June 15 through August 14, 2009. Before clicking on
the "submit" button at the bottom of this form, print a copy with your
answers for your records. The following items also must be submitted
by U.S. Mail before your application will be considered:
- Statement
of Academic Interest and Career Goals. The statement should be
one typewritten page. Include your full name and social security
number.
- Academic
Transcript. A copy of your undergraduate transcript, including
fall semester/quarter grades.
- Letters
of Recommendation. Two letters of recommendation from academic
faculty.
First Name:
M.I.:
Last Name:
Undergraduate institution:
Date of birth:
What year in school are you?:
What is your major?
Expected date of graduation:
SAT (ACT): Verb:
Math:
Test Date:
GPA:
Current address:
Street:
City:
State:
ZIP:
Daytime Phone:
Evening phone:
E-mail address:
Mailing address after (give date):
Street:
City:
State:
ZIP:
Daytime Phone:
Evening phone:
Fax:
Gender: Male:
Female:
Are you a U.S. citizen or permanent resident?: Yes:
No:
(You must be a citizen or permanent
resident to participate in STREAMS.)
Please indicate which group you include yourself in (check all that
apply):
Hispanic
Black/African American
Disabled
Native American/Alaskan Native
Pacific Islander *
(Please specify):
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