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									                                      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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