UR PREP Program: Description

UR Prep Program: Online Application

Personal InformationFirst Name: Middle Initial: Last Name:
Date of Birth: Sex: Female Male

Citizenship Please indicate your citizenship.
If a permanent resident, give your alien registration number.

Minority status Please indicate which of the following reflects your background:

African American
American Indian or Alaskan Native
Pacific Islander (inc. Fijian, Hawaiian, Samoan)
Hispanic (including Mexican American; not Puerto Rico)
Puerto Rico
Other (Combination of the Above)

Intention to enroll in a Ph.D. within two years Please indicate whether you intend to apply to, and enroll in, a Ph.D. program within 2 years of starting this PREP:
Yes
No

Present Address Street/Address:
Apt./Box #:
City:
State/Province:
Country:
ZIP Code:
Telephone:
Email address:

Permanent Address (if different than above)
Street/Address:
Apt./Box #:
City:
State/Province:
Country:
ZIP Code:
Telephone:
Email address:

Education Record University:
Address:
Degree (BS/BA): Current GPA:
Area of Degree:
Matriculation Date:
Expected Date of Graduation:
If you have attended more than one undergraduate institution, please
list the most recent above and include the next most recent below:
University:
Address:
Degree (BS/BA): GPA:
Area of Degree:
Matriculation Date:
Date of Graduation:
Please list three relevant science courses taken during the last year.
Course: Grade:
Course: Grade:
Course: Grade:
Please indicate any honors or awards received.

Other Information Please answer the following questions:
Briefly describe any prior research experience.

Briefly explain why you wish to participate in this program.

Briefly describe your scientific interests.

Briefly describe your career goals.

Research Project Information
Please list the names of three possible mentors in the UR PREP program :
First Mentor:
Second Mentor:
Third Mentor:

Recommendations: Please indicate the names of two professors who have agreed
to write letters of recommendation.
Name: Title:
Name: Title:
Letter of recommendation must be mailed directly to the
PREP Program Director. Please supply a stamped envelope to your professors
with the following address:

Dr. Edith Lord
University of Rochester Medical Center
601 Elmwood Avenue, Box 672
Rochester, NY 14642