List Below Two University of Kansas Faculty Members As Potential PBF Summer Fellowship

Name (Last, First, Middle) / Email Address / Tel Number
Applicant
Applicant’s Current Institution
No. of years of college credit / Cumulative college GPA
Major (if declared)
Are you a US citizen? (Yes/No) / If not a US citizen, please indicate your visa type

List below two University of Kansas faculty members as potential PBF Summer Fellowship Mentorsyou would like to work with during the summer of 2013. In most cases you should choose mentors from the mentors list included in the PBF Summer Fellowship Program Information and Instructions. If you have worked with another faculty member at the University of Kansas and would like to list this individual as a potential mentor, please confirm his or her willingness to sponsor you in their research program. The mentor’s research work must have broad relevance to pulmonary diseases.

Name of potential mentor(include degree, i.e., MD or PhD)
Academic Department
Name of potential mentor(include degree, i.e., MD or PhD)
Academic Department

STUDENT (Applicant):

If I am awarded a Parker B. Francis (PBF) Summer Fellowship I agree to submit a final report of accomplishments no later than September 30, 2013. I (or a parent or guardian if I am a minor) also agree to sign a Voluntary Consent Form releasing the Francis Family Foundation from any liability arising from my research activities. I understand PBF Summer Fellowships are normally awarded only once to a single individual.

APPLICANT’S SIGNATURE / DATE

PBF Summer Fellowship Application Form (rev. 2/13) Page 1

APPLICATION: 2013Parker B. Francis Summer Fellowship Program

FORMAT REQUIREMENTS:.5” margins, single-line spacing Arial 11-point font

RECOMMENDATIONS

Two recommendations (completed on the PBF Summer Fellowship Program recommendation form) are required with this application. The individuals providing recommendations may be either science high school teachers or college faculty. List names and contact information of the individuals providing your recommendations below.

Name
Title
Institution
Email
Telephone
Name
Title
Institution
Email
Telephone

How will a summer research experience contribute to your career plans?

Do not exceed 400 words (Arial 11-point font size, double-line spacing).

PREVIOUS RESEARCH EXPERIENCE AND PUBLICATIONS (if any)

List any previous research experience and publications here.

SPECIAL ACHIEVEMENTS OR HONORS

List any academic special achievements or honors here.

GOALS FOR A SUMMER RESEARCH FELLOWSHIP

Describe why you would like to work with the mentors you have chosen and what your project might be. Using information from the mentors’ website or other online sources, explain why you are interested in the mentors’ research area(clinical or laboratory science).

Do not exceed 400 words (Arial 11-point font size, double-line spacing).

PBF Summer Fellowship Application Form (rev. 2/13) Page 1