APPLICATION COVER SHEET
Rutgers University/Robert Wood Johnson Medical School
Summer Undergraduate Research Program in Neuroscience
Summer 2015 Session

I. BIOGRAPHICAL INFORMATION

First Name: / Last Name:
Date of Birth (mm/dd/yyyy): / Gender:Click HereMaleFemale
Permanent (Home) Address:
Street Address:
City:
State: Zip Code:
Telephone (Home): / Address at School:
Street Address:
City:
State: Zip Code:
Cell phone: / School Email:
Personal Email:
Racial/Ethnic Background: Click HereWhiteHispanic/LatinoBlack or African AmericanAsianAmerican IndianNative HawaianOther / Country of Birth:
US Citizen/Permanent Resident: Yes No
Parent/Guardian highest level of education: Parent/Guardian 1: Click HereSome High SchoolHigh School or EquivalentSome CollegeAssociates DegreeBachelors Degree (BA or BS)PhDMDOther Post Graduate/Professional
Parent/Guardian 2: Click HereSome High SchoolHigh School or EquivalentSome CollegeAssociates DegreeBachelors Degree (BA or BS)PhDMDOther Post Graduate/Professional


II. ACADEMIC INFORMATION

University/College Name: / Expected Degree:Click HereBABSBA/MD (6 Years)BS/MD (6 Years)PharmDUndeclared
Expected Year of Graduation:Click Here201620172018
Major: / GPA:


Please list the names of persons from whom reference letters were requested (min of 2 required):

1)

Name Affiliation Relationship to Applicant

2)

Name Affiliation Relationship to Applicant

3)

Name Affiliation Relationship to Applicant


III. CAREER PLANS

Please check the boxes that best describes your future plans:

I am sure I will apply to Graduate School
I am sure I will apply to Medical School
I may apply to a joint MD/PhD Program / I am leaning toward applying to Graduate School
I am leaning toward applying to Medical School
I am not sure what I will do yet


If you plan or have scheduled to take the following exams, please indicate dates below:

GRE: Plan to take Yes No Date (if known) (mm/dd/yyyy)
MCAT: Plan to take Yes No Date (if known) (mm/dd/yyyy)

IV. STATEMENT OF INTEREST
Please answer the following questions. Your combined answers should not exceed the remainder of this page.
1) Why would you like to participate in our SURP?
2) If you have had prior research experience, briefly describe the objectives of the project and your contribution. If you have not had prior research experience, briefly describe what you would like to learn this summer (note that prior research is NOT a requirement).
3) What are your current near-term (next 3-4 years) goals for your education and career?
4) Please tell us something unique about yourself that may set you apart from the other applicants.