NI Summer Research Program

NEUROSCIENCE INSTITUTE
2015 SUMMER RESEARCH PROGRAM

APPLICATION

* Today's Date

* First Name

Middle Initial

* Last Name

* Date of Birth (ex. 01/01/1987)

* LOCAL ADDRESS

Apt./Room:

* City

* State

* Zip Code

HOME ADDRESS (if different from above)

Apt./Room:

City

State

Zip Code

Country

* Home Phone

Contact number after leaving school

* E-mail

* Emergency Contact Name & Number

* Type of Medical Insurance

* Institution

* GPA

* Major

Minor

Classification

* Student Status

* Year in School

* Career Goals (M.D., Ph.D or M.D./Ph.D.)

Other

Please upload your CV.

Please upload your letter of interest.

Please upload your research experience (1-2 pages).

Please mail your (1) official transcripts and (2) two letters of recommendation by April 12, 2013 to the address below:

Morehouse School of Medicine
Neuroscience Summer Research Program
720 Westview Drive SW
Atlanta, GA 30310

For more information call (404) 756-5785.

* Indicates Response Required