Summer Research Trainee Program
2013 Application
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Please type your responses. Forward completed application and supporting materials to: Massachusetts General Hospital, Multicultural Affairs Office, 55 Fruit Street, BUL 1-123, Boston, MA 02114. The deadline for submission of this application is Friday, February 15, 2013. Acceptance decisions will be made by Friday, March 1, 2013 (tentative).

Part 1: PERSONAL DATA

Last Name / First Name / Middle Name
Mailing Address (Street, Apt/Suite, City, State, Zip code):
Permanent Address (If different than above):
Current Phone Number: / Cell Phone: / Permanent Phone:
Social Security Number (SSN): / Place of Birth: / Date of Birth (DD/MM/YY):
E-mail Address (school): / E-mail Address (Personal, i.e. Hotmail):
Citizenship Status: / Gender:
How did you learn about this program? / Ethnicity:

Part 2: BACKGROUND INFORMATION

College: / Degree:
Major(s): / Year of Graduation:
Medical School: / Year of Graduation:
Honors and Awards:
Extracurricular activities:
Previous Research Experience:

Part 3: PERSONAL STATEMENT

Please attach your personal statement on a separate page. Describe in no more than 500 words your educational and professional goals and how your participation in SRTP will assist in meeting your goals. Be sure to articulate your qualifications and reasons for wishing to participate in this program.

Part 4: SPECIFIC RESEARCH PREFERENCE

While we cannot guarantee a research opportunity in a specific area, what is the area(s) of research that you prefer (list in order of preference)? If you need additional information about research at MGH, please visit the MGH website at http://www.massgeneral.org/mao

Part 5: RECOMMENDATION LETTERS AND TRANSCRIPT

Attach a recent official transcript and a resume. If you are a rising first or second year medical student or in a graduate program, please include your undergraduate transcript as well.
Please list the three (3) references that will be writing in support of your application. They should be faculty members or laboratory advisors who have worked closely with you.
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Part 6: LISTING OF CURRENT AND PENDING OTHER SUPPORT

If you’re being funded by another agency, please list. If none, report none.
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B.
C.

Part 7: LISTING OF OTHER PROGRAMS TO WHICH YOU HAVE APPLIED

Please list other programs that you have applied to.
Specify if notification is pending or you have been notified of acceptance and the amount you will
be awarded.
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All information submitted is true to the best of my knowledge and any misrepresentations will be cause for rejection of my application and dismissal from the program.

I understand the information contained in this application is confidential and will only be used by the Massachusetts General Hospital for review and selection.

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Signature of Applicant Date