Application for Parviz Azari Undergraduate Summer Research Fellowship Program

Due Date: March 1, 2009

We strongly encourage you to prepare your longer statements in a word processing program on your computer and then paste them into the box provided.

Please fill in all fields in this form. For fields that do not apply to you, enter "NA". Personal Background Title: Mr. Mrs. Miss Ms. First Name: Last Name: Nickname: Email Address: Birthdate: United States Citizen: Yes No Gender: Male Female Ethnicity: American Indian or Alaskan Native Pacific Islander African American, not Hispanic Hispanic Caucasian/White not of Hispanic origin Other I do not wish to provide this information Other Ethnicity: Current Address Street Address: Street Address (2): City: State or Province: Zip Code: Phone Number: Permanent Address Click here if your permanent address is the same as your current address: Street Address: Street Address (2): City: State or Province: Zip Code: Phone Number: Education Major: Currently enrolled as: Freshman Sophomore Junior Non-graduating Senior Date Spring term ends: Date Fall term begins: Anticipate taking: GRE Exam MCAT Exam When? Do you plan to enroll in: Graduate School Medical School When? Have you participated in undergraduate research previously? Yes No If yes, when and where? College Science Courses Already Taken: Cumulative GPA: Science GPA: Science Credits Taken: Please List: Currently Enrolled Courses: References Provide the names of two chemistry and/or life sciences (biochemistry, biology, biomedical sciences, etc.) professors who know you well and will submit letters of recommendation. First Reference Title: Dr. Mr. Mrs. Miss Ms. First Name: Last Name: Email: Second Reference Title: Dr. Mr. Mrs. Miss Ms. First Name: Last Name: Email: Desired Research Advisors List the three professors in our program whose research most interests you and whose group you would like to join for the summer. Choice One: Choice Two: Choice Three:   Explain why you have chosen these mentors. What about their research methods interests you?     What do you hope to gain from the Azari summer research experience?     Please submit an application only once. If you have a major change to something after you submit, please contact us at marti.stokes@colostate.edu.