Minority Health and Health Disparities International Research Training (MHIRT)

Sponsored by the National Institutes of Health

Minority Science Programs (MSP) School of Biological Sciences

Program Director Dr. Luis Mota-Bravo

University of California, Irvine

2016 STUDENT APPLICATION

Applications will be reviewed starting on Monday February 8, 2016. Please use a computer to fill in the gray areas of this application, print the completed application and sign it.

Legal Name Male --

Family/Last Name (Surname)First NameMiddle Name FemaleU.S. Social Security #

UCID number (if applicable):

Different names that may appear on your academic records:

Mailing Address (Use until: )Permanent Address

No. and Street No. and Street

City and State City and State

ZIP or Country Zip or Country

Cell phone E-mail:

E-mail: Permanent Telephone:

Birthplace: Birthdate:

City, State or CountryMonth/Day/Year

Ethnicity:If Native American, your tribal affiliation:

Country of Citizenship:

If you are not US Citizen, are you a US Permanent Resident?NoYes

Current Class Status:

Freshman: Sophomore: Junior: Senior: Graduate: Medical:Other:

Specify major/area:Date your Fall 2016 classes begin: (this field must be completed)

Degree Objective: Master’s Degree M.S./Ph.D. M.D./Ph.D.

Ph.D. DegreeOther:

Specific area of interest:

List in chronological order all colleges and universities attended since high school. Please include institutions you are currently attending and any previous work completed in preparation for the MHIRT program. One copy of official transcripts are required for each institution listed.

College/University
and Location / Dates Enrolled
Mo/Yr -Mo/Yr / Units Completed / Degree and
Date conferred / Cum. GPA / Major Field
of Study

Indicate your undergraduate science G.P.A:

Describe academic work in progress and anticipated courses of study prior to participation in MHIRT.

What factor(s) made you interested in the Biological/Biomedical Sciences?

Describe previous research training and other experiences which are relevant to MHIRT.

What are your plans to continue your research training after your participation in the MHIRT Program (for example, plans for the enrollment in graduate school)?

Indicate your order of preference for a particular MHIRT research training area and foreign site according to the program announcement.

1.

2.

3.

Describe the level of competence in speaking, understanding, reading and writing, languages other than English, and state how this ability was acquired.

With your application, please include:

  • Copy of transcripts
  • The transcripts of UCI students should show that they have passed Bio Sci 194S (Safety and Ethics in Research)or students should enroll in Bio Sci 194S during Spring 2016. Students are required to enroll in Spring 2016 Bio 197 MSP Research Seminar. Students that are not participating in UCI MSP programs (MBRS, MARC and URM) and have done researchshould submit a letter of recommendation from their research advisors describing their research experience.
  • Two page personal statement (see form below)

Note: The MSP Selection Committee will not review incomplete applications. If you are pre-selected, you will be contacted to set an appointment for an interview.

I hereby apply for admission to theMinority Health and Health Disparities International Research Training (MHIRT) at the University of California, Irvine, and certify that to the best of my knowledge all of the above statements are true and complete. I understand that submitted records and letter of recommendation will not be returned, copied, or forwarded. I authorize the UCI Minority Science Programs personnel to access my student records and monitor my academic progress. I agree to abide by the university policies and stated in the UCI General Catalogue.After my participation in MHIRT, I agree to maintain contact with the UCI Minority Science Programs personnel to track my career development to evaluate the outcomes of MHIRT.

______

SignatureDate

Return this application and all supporting documents to: MHIRT, Attn: Dr. Marlene de la Cruz, University of California, Irvine, 1134 Biological Sciences III, Irvine, CA 92697-2527

Telephone (949) 824-2589, Fax: (949) 824-6599, e-mail:

Application for the Minority Health and Health Disparities International Research Training (MHIRT) at the University of California, Irvine

Statement of Purpose

Legal Family Name (Last Name)First NameMiddle Name

State your general reasons for applying to MHIRT and your specific career interest. Please include background, research interests and experience, future educational goals, personal attributes and program expectations. If applicable, include you experience in laboratory methods and level of expertise.Please use a computer to fill in the gray areas of this form (you may copy/paste from other documents). Please do not exceed 2 pages.

______

SignatureDate

Applications will be reviewed starting on Monday February 8, 2016.

Return this application and all supporting documents to: MHIRT, Attn: Dr. Marlene de la Cruz, University of California, Irvine, 1134 Biological Sciences III, CA 92697-2527

Telephone (949) 824-2589, Fax: (949) 824-6599, e-mail: