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| First
Name*
|
Last
Name*
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| E-mail
Address*
(preferably not student email address)
|
| Phone
Number*
(include area code) |
| Current
Address: |
| |
Street
Address* |
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| |
City*
|
State*
|
ZIP*
|
| Home
Address: |
| |
Street
Address * |
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| |
City*
|
State*
|
ZIP*
|
| Foreign
Address: |
| |
Street
Address |
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| |
City
|
Country
|
| U.S.
Citizen*
Yes
No |
DOB*
e.g. 09/19/1980 |
| If
you are not a citizen of the U.S., what is your status?
|
| Racial/Ethnic
Background (optional) |
Gender
(optional) |
| Are
you the first person to attend college in your immediate family?
Yes
No |
Do
you come from an educationally or economically disadvantaged background?
Yes
No
Answer "Yes"
if you come from an environment that has inhibited you from obtaining
the knowledge, skill and abilities required to enroll in and graduate
from a school; OR if you come from a family with an annual income
below a level based on low-income thresholds according to family size
published by the U.S. census.
If Yes, please explain:
|
School*
|
State/Country
of School*
|
Major*
|
Current
GPA*
Priority for > 3.
|
| Class
Level*
|
Anticipated
Graduation Date*
(month/year) |
| High School students may ONLY apply to the department of Pharmacology and Experimental Neuroscience |
|
Career Goals* |
If "other" please list |
Are you fluent in a language other than English?
Yes
No
What language/s?
|
Please rank in order of preference your top 3 choices (use
1, 2, or 3).
* A copy of the
required documents must be sent directly to each of your selections.
Please review the
"requirements" section for further information on supporting
documentation.
Applications deadlines are listed below. The number in parentheses after each department indicates the number of positions that were available last summer (2011). |
|
|
Requirements |
Deadline |
| Anesthesiology (2) |
Application is now closed |
|
|
Biochemistry/Molecular
Biology (2) |
 |
March
1 |
|
Cellular and Integrative
Physiology (12) |
|
March
1 |
|
College of Public
Health (5) |
|
March
1 |
Eppley Institute
for Research in Cancer (5)
(Applicants
must be US citizens or permanent residents to apply.)
|
|
March
1 |
Internal Medicine (22)
(Applicants
must be US citizens or permanent residents to apply.)
|
|
March
1 |
MD/PhD Summer Undergraduate
Research Program (10)
(Applicants
must be US citizens or permanent residents to apply.)
|
|
March
1 |
|
Pathology/Microbiology (3) |
|
March
1 |
|
Pediatrics |
|
March
1 |
|
Pharmaceutical Sciences (1) |
|
March
1 |
|
Pharmacology &
Experimental Neuroscience and Center for Neurovirology & Neurodegenerative
Disorders (8) |
|
March
1 |
Summer Undergraduate/Graduate
Research Program (SURP) for Members of Underrepresented Groups (9)
(Applicants
must be US citizens or permanent residents to apply.) |
|
April
15 |
|
By requesting that my application be forwarded to these Departments, I acknowledge the time commitment of approximately 10 weeks/40 hrs each week (or otherwise prescribed by the dept) if accepted to their program.
I understand that my acceptance, if offered a position, is contingent upon fulfilling the
immunizations required by the University of Nebraska Medical Center. I agree to submit
the requested immunization form by May 15th, 2012.
Please note: The Hepatitis B vaccination is a 3 dose series that can
take up to 7 months to complete. You will be considered ineligible if
you have not completed the series by May.
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