PrIMER APPLICATION

NOTE: An eligible applicant is:

-Currently enrolled in full-time classes as a Sophomore (will be a Junior in Fall, 2017)

-A US Citizen or permanent resident

-An Underrepresented minority

BACKGROUND INFORMATION

Name: ______

Mailing Address:______

Cell Phone: ______Other Phone: ______

Current Undergraduate University:______

University E-mail Address: ______

Date of Birth: ______/______/______Sex: ___ Male ___ Female

Country of Birth: ______US Citizen: ___ Yes ___ No

Country of Citizenship (or Permanent Resident): ______

Race/Ethnicity (mark all that apply):

___ American Indian or Alaska Native ___ Native Hawaiian or Other Pacific Islander

___ Black or African American ___ Asian (Far East, Southeast Asia, or Indian Subcontinent)

___ Hispanic/Latino: ___ White (non-Hispanic)

___ Other (please indicate):______

How did you hear about this Program?:______

ACADEMIC HISTORY

Current Student Status: ___ Full-time ___ Part-time

Academic Standing: ___ Freshman ___ Sophomore ___ Junior ___ Senior

Total college credits to date: ______Cumulative Current GPA:______

Major: ______Minor: ______

Cumulative science GPA (include all undergraduate science courses in this calculation): ______

Professional/career interest: ______

Do you plan to apply to graduate school: ☐ Yes ☐ No

Transfer Students Only:

From what institution did you transfer? ______

GPA at transfer: ______

Have you ever participated in ongoing lab research (NOT lab courses)? ___ Yes ___ No

If so, please briefly describe your lab work/experience here:

Have you ever taken a research training course or seminar? ___ Yes ___ No

If so, please list the course and when it was taken:

REQUIREMENTS

Letters of Recommendation

Two letters of recommendation are required for this application at least one of which should come from a professor from your current undergraduate institution.

Statement of Purpose:

List your reasons for applying to this program. (This can include such topics as: Previous lab or research experience, specific environmental health science interest, graduate school plans, etc.)

Signature______

Date______

All documents should be sent to

Thank you!