Your permanent address (street, city, state, zip)
Your local address if different (street, city, state, zip) **Birth Date (MM/DD/YYYY):
Gender: Male Female
Are you a U.S. Citizen? Yes No
Ethnic Identity (optional): American Indian/Native Alaskan Native Hawaiian/Pacific Islander Black (not of Hispanic origin) White (not of Hispanic origin) Asian Hispanic/Latino More Than One Race Decline to Answer Native Hawaiian/Pacific Islander Other If other please specify:
Will you require housing at DSU for the summer? Yes No
Do you have a car (and need a parking permit?) Yes No
Name and address of institution attended:
Entry date (MM/YYYY) Expected graduation date (MM/YYYY) Major Cumulative GPA Class: Freshman Sophomore Junior Senior
Ultimate level of degree desired: Associates Bachelor's Master's Doctorate
Academic Awards & Honors (briefly describe the honor or award and include the date received) (text box can be resized via handle @ bottom right corner - PLEASE LIMIT TO 400 WORDS)
Activities, Accomplishments, and Career-Related Experiences (Briefly describe the activity, accomplishment, or experience and give the date it occurred) (text box can be resized via handle @ bottom right corner - PLEASE LIMIT TO 400 WORDS)
Two references recommending your acceptance into this program are required. These individuals should be professionals in a science field.
Recommender #1: (Please include name-first and last, professional title & department, institutional affiliation, institution city & state, phone number, and email address) (text box can be resized via handle @ bottom right corner)
Recommender #2: (Please include name-first and last, professional title & department, institutional affiliation, institution city & state, phone number, and email address) (text box can be resized via handle @ bottom right corner)
Emergency Contact: Parent Spouse Guardian
Please provide following information about your emergency contact: Name-first & last; address-street, city, state, zip; and phones-cell, work, home (text box can be resized via handle @ bottom right corner)
If selected for the program, I would prefer to work in a lab at: Delaware State University University of Delaware A.I. duPont Hospital/Nemours No Preference/Don't Know
Using the file attachments button, please attach (1) a PDF copy of your transcript, and (2) a personal statement of no more than two pages describing your experience, interest, and career goals related to neuroscience and research. Most types of text documents including PDF, Word, text, RTF, and more can be uploaded.
If you already know the Delaware neuroscientist with whom you would like to work, please discuss that in your statement.
File attachments: (Attach transcript in PDF file format) (Attach personal statement per guidance above)
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