Fayetteville State University - Biomedical Research Program

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APPLICATIONS

Fayetteville State University
Minority Biomedical Research Support Program
Research Initiative for Scientific Enhancement (MBRS-RISE)

FSU-RISE APPLICATION FALL 2008

Instructions: Answer all questions. If question is not applicable to you, indicate by N/A. Deadline: May 28, 2008.

1	NAME	LAST NAME FIRST MI
2	SOCIAL SECURITY #
3	CURRENT ADDRESS	TELEPHONE NO. EMAIL ADDRESS
4	PERMANENT ADDRESS (if different from current)	CITY/STATE ZIP
5	DATE OF BIRTH	PLACE OF BIRTH MM DD YY CITY STATE
6	US CITIZENSHIP	CITIZEN US NON-CITIZEN NATIONAL PERMANENT RESIDENT OTHER (Specify)
7	GENDER	FEMALE MALE
8	RACE OR ETHNIC GROUP	AFRICAN AMERICAN NATIVE AMERICAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER ALASKAN NATIVE CAUCASIAN HISPANIC AMERICAN OTHER (Specify)
9	STUDENT CLASSIFICATION	AREA OF DECLARED/INTENDED MAJOR SEMESTER/SESSION GPA: CUMULATIVE GPA
10	CURRENT COURSE LOAD IN SEMESTER HOURS	ANTICIPATED GRADUATION DATE MM DD YY
11	CURRENT SOURCE OF FINANCIAL SUPPORT (CHECK ALL THAT APPLY):	CHANCELLOR'S SCHOLARSHIP GRANT LOAN HONORS NASA SCHOLAR OTHER (SPECIFY)
12	ARE YOU CURRENTLY EMPLOYED? YES NO IF YES, INDICATE EMPLOYER AND HOURS PER WEEK (Employer) (HRS PER WK.)
13	INDICATE FIRST AND SECOND CHOICE OF RESEARCH AREA THAT YOU HAVE AN INTEREST IN WORKING IN: CHEMISTRY PHYSICS COMPUTER SCIENCE MATH BIOLOGY
14	BRIEFLY INDICATE YOUR REASON(S) FOR WISHING TO BECOME A FSU-CAMP RESEARCH SCHOLAR AND INDICATE YOUR AREA OF RESEARCH INTEREST. (YOU MAY USE A SEPARATE SHEET).
15	DO YOU PLAN TO PURSUE RESEARCH ACTIVITIES/GRADUATE STUDIES UPON GRADUATION FROM FSU? YES NO EXPLAIN:
16	PREVIOUS RESEARCH ACTIVITIES (IF NONE, INDICATE NONE)
17	PERSONS TO BE CONTACTED IN CASE OF EMERGENCY. (Name) (Address) (Telephone No.) (Relationship)
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I CERTIFY THAT ALL OF THE STATEMENTS MADE IN THIS APPLICATION AND ANY ATTACHED DOCUMENTS ARE TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT FALSE INFORMATION MAY BE GROUNDS FOR REJECTION OF MY APPLICATION AND/OR DISMISSAL IF I AM SELECTED. Signature of Applicant Date _____________________________________________________________________________________________________ OFFICIAL USE ONLY ACCEPTED: YES NO DATE PROGRAM DIRECTOR
FAYETTEVILLE STATE UNIVERSITY IS A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA

"Fayetteville State University is a member institution of The University of North Carolina, which is committed to equality of educational opportunity and does not discriminate against applicants, students, or employees based on race, color, national origin, religion, sex, age, or disability."