Application for Undergraduate Program

General Information

*Last Name :

*First Name :

Middle Initials :

Address :

City :

State :

Zip :

*Telephone :

*E-mail :

* Date of Birth :

*Social Security Number :

(mm/dd/yyyy)

(xxx-xx-xxxx)

Please choose one of the following categories which you identify with the most :

If other, please specify :

Health Insurance

Do you have health insurance? Please note that this will not affect your acceptance in any way.

Yes No

If so, will you be able to provide a copy of your insurance card upon acceptance?

Yes No

Program Dates

We have two program schedules to accommodate students on either the quarter or semester system. Please choose the program track you will be able to commit to for the entire 12 weeks.

1. Semester System Track

Yes, I am available to attend the Semester System Track.

2. Quarter System Track

Yes, I am available to attend the Semester System Track.

Educational Background

Beginning with the institution you are currently attending, please list the colleges, universities, and high school you have attended

Name of School/Location (City/State)

Major/Expected Degree

Expected Graduation Date (Month/Year)

Overall GPA

Current year in college : Freshman Sophomore Junior Non-Graduating Senior Other (please specify)

Extra Curricular Acitivities

Please list activities and provide a brief description.

Acitvity

Description

Employment Information/Work Experience

Please list all work experience, including non-research related.

Company Name

Dates of Employment

Title/Position

References

Recommender 1:

Name :

Title :

Institution :

Telephone Number :

E-mail :

Date asked for letter :

Recommender 2:

Name :

Title :

Institution :

Telephone :

E-mail :

Date asked for letter :

Official Transcripts

Date ordered:

Send to: Marianna Sarkissyan, Division of Cancer Research & Training
Charles R. Drew University of Medicine and Science
1731 E 120th St, Los Angeles, CA 90059

Short Answer Questions

Please answer the following questions in the area provided.

1. What are your hobbies or main interests outside of school ?

2. What other summer programs are you applying to ?

3. What are your long term education and career objectives ?

4. Briefly describe any independent study or projects that you have completed.

Essay Question

Please use the limited space below to answer your essay question.

*What are your expectations of the Charles Drew University- Division of Cancer Research and Training Undergraduate Cancer Research Training Program and what do you hope to gain from your participation in the program? How will it help you achieve your academic and career objectives stated in the short answer portion?

I hereby certify that the above information provided on this application is correct to the best of my knowledge.

*Signature : *Date :(mm/dd/yyyy)

How did you hear about UCRTP ?