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)

RISING SCHOLARS PRE-FRESHMAN WORKSHOP APPLICATION

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

NOTE: This workshop is held from 10:00AM - 4:00PM, Monday-Thursday and 10:00AM-12:00PM, Friday for four(4) weeks, beginning July 1, 2008 and ending July 31, 2008.

*The deadline for submission is June 15, 2008 by 12 midnight Eastern Standard Time.

1	NAME	LAST NAME FIRST MI
2	SOCIAL SECURITY #
3	CURRENT ADDRESS	CITY/STATE ZIP
	LOCAL AREA CODE /TELEPHONE #	EMAIL ADDRESS
4	PERMANENT ADDRESS (if different from current)	CITY/STATE ZIP
5	DATE OF BIRTH	MM	DD		YY	PLACE OF BIRTH (CITY, STATE)
6	GENDER	FEMALE MALE
7	US CITIZENSHIP	CITIZEN US NON-CITIZEN NATIONAL PERMANENT RESIDENT OTHER (Specify)
8	RACE OR ETHNIC GROUP	AFRICAN AMERICAN		NATIVE AMERICAN		CAUCASIAN
		ALASKAN NATIVE		NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
		HISPANIC AMERICAN		OTHER (Specify)
9	STUDENT CLASSIFICATION	CUMULATIVE GPA SAT SCORE: VERBAL MATH
10	DO YOU PLAN TO ENROLL AT FSU THIS FALL?	YES NO IF YES, WHAT IS YOUR INTENDED MAJOR:
11	EMPLOYMENT RECORD (list most recent first). USE ADDITIONAL SHEET IF NECESSARY A. (Employer) (Position) (Date) B. (Employer) (Position) (Date)
12	WHICH OF THE FOLLOWING CAREERS ARE YOU MOST INTERESTED IN PURSUING? RESEARCH SCIENTIST MEDICAL DOCTOR VETERINARIAN DENTIST LAWYER PROFESSOR OTHER (Specify)
13	ON A SEPARATE PAGE BRIEFLY INDICATE YOUR REASON(S) FOR WISHING TO BE A PARTICIPANT IN THE PRE-FRESHMAN RISING SCHOLARS WORKSHOP. ALSO, DISCUSS YOUR CAREER GOALS AND INTERESTS. INDICATE ANY RESEARCH EXPERIENCE YOU HAVE HAD.
14	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 _____________________________________________________________________________________________________

The MBRS-RISE Program is sponsored by a grant from the National Institution of Health 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."