Submitted to:
Prem S. Kahlon, Ph.D.
MARC Program Director
Department of
Biological Sciences
Harned Hall Room 314
3500 John A. Merritt
Blvd
Tennessee State
University
(615) 963-5789
APPLICATION
MINORITY
ACCESS TO RESEARCH CAREERS PROGRAM
NAME
(please print or
type) First
Middle
Last
SSN
MALE
FEMALE
LOCAL MAILING
ADDRESS:
TELEPHONE:
( )
PERMANENT HOME
ADDRESS:
TELEPHONE
( )
BIRTH DATE:
EMAIL ADDRESS
MAJOR:
__________________________ UNDERGRADUATE
STANDING________________
ESTIMATED DATE OF
GRADUATION :
THIS OFFICE MUST BE
NOTIFIED OF ANY CHANGE OF ADDRESS OR TELEPHONE NUMBER
MARITAL/DEPENDENT
STATUS:
(Please circle)
1. Single
2. Married
3. Divorced
4. Separated
5.Widowed
Number of Dependents:
____________________
Ages: _______________________
Do you currently
receive any grants, loans, scholarships, or work-study support ?
______
Yes _______ No
If yes, state
which:
_________________________________________________________________________
IF YOU ARE NOT A U.S.
CITIZEN, DO YOU HAVE A PERMANENT VISA?
EDUCATIONAL TRAINING:
Name and Location of
Date
Awarded
Educational
Institution
Dates Attended
Major
Minor
Degree or Expected
ACADEMIC HONORS,
SCHOLARSHIPS, FELLOWSHIPS, AND ASSISTANTSHIPS:
Awards
College or University
Inclusive Dates
EXTRACURRICULAR
ACTIVITIES AND INTERESTS:
MEMBERSHIPS IN
SCIENTIFIC or STUDENT ORGANIZATIONS:
RESEARCH EXPERIENCE,
PRESENTATIONS AND/OR PUBLICATIONS, IF ANY:
Number of Units Completed: Number
of Units in Progress:
GPA Major:
GPA Science:
GPA Overall:
_______________________________________
_________________________
SIGNATURE
DATE
How did you learn
about the MARC Program? (Please check all that apply):
Instructor
Friend
Brochure
Other
Program s (i.e., MBRS, McNair, HCOP, etc)
Other
(please specify)
What do you hope to
gain by participating in the MARC Program?
What are your
expectations of the MARC Program?
Why do you feel you
are a good candidate for the MARC Program?
The highest degree I
expect to obtain is: (Please circle):
Bachelors
Masters
Ph.D.
M.D.
OTHER
LIST THREE PERSONS FROM WHOM YOU HAVE ASKED TO
COMPLETE CONFIDENTIAL REFERENCE FORMS OR LETTERS OF RECOMMENDATION.
AT LEAST ONE MUST BE A RESEARCHER OR A TEACHER:
Name
Address or email
Association
IT IS YOUR RESPONSIBILITY TO ENSURE THAT THESE LETTERS REACH THE
MARC OFFICE
CONFIDENTIAL
REFERENCE
MINORITY ACCESS TO
RESEARCH CAREERS
UNDERGRADUATE
RESEARCH PROGRAM
Tennessee State
University
I.
TO THE APPLICANT: Please request a current or former instructor,
advisor, or supervisor who is in a position to evaluate your potential
for biomedical research to complete this form. If you have been
away from an academic institution for some time, the form may be given
to some other person who is able to comment on your academic
qualifications. Please type or print the following information
before submitting the form for completion.
APPLICANT'S
NAME:
ADDRESS:
NAME OF EVALUATOR:
****************************************************************
II.
TO THE EVALUATOR: This form
is for your convenience only. If you prefer to give your
comments in a letter, please feel free to do so.
A.
How long and in what
capacity have you known the applicant? How well do you think he
or she will do as an undergraduate student carrying on advanced study
in his or her field of interest?
B. What is your estimate of the student's previous
accomplishments, intellectual independence, capacity for analytical
thinking, ability to organize and express ideas clearly (orally and in
writing), drive and motivation?
C. Do you know of any special considerations which should
be taken into account in planning for the student's research
activities?
D. What do you feel are the student's strongest points?
His or her weakest points?
E.
