SDSU / UCSD / UM-DULUTH MIRT APPLICATION
Last Updated: 10/31/2011
MIRT
MINORITY INTERNATIONAL RESEARCH TRAINING PROGRAM
SDSU/UCSD/UM-DULUTH CONSORTIUM
Sponsored by: The National Center for Minority Health and Health Disparities (NCMHD)
MIRT is an international research experience that prepares students for a career in
biomedical research. The long-term objective is to increase the number of
underrepresented minority faculty in biomedical science.
Directions: Download this file, and double-click on a text box to enter your information.
STUDENT APPLICATION
Today’s Date: Age: Birth Date:
Name:
(First Name, Middle Name, Last Name)
Social Security Number:
Ethnicity (not required). Please select one from the drop-down menu: _
Current Address:
City: State: Zip:
Above Address Valid Until:
Permanent Address:
City: State: Zip:
Phone (H): ( ) Phone (W): ( )
Cell Phone: ( ) E-mail:
Web Page
Name of Parent/Guardian:
Address:
City: State: Zip:
Please respond by choosing one:
a) Are you a U.S citizen? (yes or no) _
b) If you are not a U.S. citizen, are you a permanent resident? (yes or no) _
c) What type of visa do you hold?
d) What is your visa status?
e) What is your registration number?
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SDSU / UCSD / UM-DULUTH MIRT APPLICATION
Last Updated: 10/31/2011
ACADEMIC INFORMATION
Community College Name:
Start Date: Finish Date: Overall GPA: Science GPA:
Did you receive financial aid? _
Undergraduate College or University Name: Start Date:
Degree granted: -OR- Current class status:
Major: Major GPA:
Minor: Overall GPA:
Did you receive financial aid? _
Which of the following courses have you taken? (Please include grade):
Calculus: None
Physics: None
Inorganic Chemistry: None
Organic Chem.: None
Physical Chem.: None
Cell Molecular Biology: None
General Biology: None
Were/Are you a member of: Yes
Bridges to the Future Program ………………………… When?
Minority Biomedical research Support (MBRS) ……… When?
Graduate Access to Research Careers (MARC).………. When?
Alliance for Minority Participation (AMP) ………….… When?
McNair Program…….…….…….…….…….…….……... When?
GRADUATE SCHOOL PLANS
Are you interested in any of the following programs? Check box if yes.
Yes Year: University Name:
Ph.D.:
Medical Scientist (MD Ph.D.)
Masters:
PERSONAL STATEMENT
Please answer this question thoroughly on separate pieces of paper (typed, 12 point,
double-spaced).
1. Briefly tell us about yourself; explain why you decided to apply to this program
and how you expect that the experience of doing research at an international site
might help your career development in the biomedical sciences. Please explicitly
define your research-driven hypothesis that you will test at the international site.
Please have your mentor review and approve the research that you will be doing at
the international site. (See faculty recommendation form.)
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SDSU / UCSD / UM-DULUTH MIRT APPLICATION
Last Updated: 10/31/2011
Please answer this only if it is applicable: Which international university or site are you
planning to attend this year? Often students conduct research with an advisor who has
contacts at an international site. (However, MIRT also welcomes applications from
students who are interested in the research experience but have not had the experience
to develop contacts at their university. Please feel free to apply, in either situation!)
Name of institution:
Name of project:
Country to which you are traveling:
How long will you be there?
State the title of your paper:
Are you planning to do any presentations?
Are you taking any courses there?
PLEASE NOTE! MIRT is also accepting applications for research proposals that deal
with ethical research questions at international sites. Besides strict biomedical research,
MIRT welcomes these kinds of proposals.
I hereby certify that the information in this application is correct to the best of my
knowledge and belief.
Applicant’s Signature Date
PLEASE SEND THE FOLLOWING TO DR. ROBERT POZOS,
DEPARTMENT OF BIOLOGY, SDSU. APPLICATIONS CAN BE
DROPPED OFF IN PERSON, FAXED, OR SENT VIA MAIL.
FAX: (619) 594-3484
1. APPLICATION
2. UNOFFICIAL OR OFFICIAL TRANSCRIPT
3. PERSONAL STATEMENT
Please call or e-mail with any questions:
Dr. Robert Pozos
College of Sciences
San Diego State University
5500 Campanile Drive
San Diego, CA 92182-4614
Phone: (619) 594-2581
Fax: (619) 594-3484
bpozos@sciences.sdsu.edu
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