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The UMDNJ - School of Osteopathic Medicine
2009 Summer Pre-Medical Research Education Program (PREP) Application
Instructions: Please type or print clearly in black ink. Complete all sections of the application. Enclose or forward a
transcript of all college course work with the application and mail to the address below. Letters of recommendation
should be mailed by the person(s) completing the form to the same address. Please ensure that all materials reach our
office no later than the application deadline of Friday, February 20, 2009.
Personal Information
1. Name: Last_______________________________ First__________________________ Middle__________
2. Current Mailing Address: Street____________________________________________________________
City_______________________________ State____________________ Zip__________
3. Permanent Mailing Address: Street___________________________________________________________
City_______________________________ State____________________ Zip__________
Email Address: _____________________________________
4. Home Phone: (_____)_________________ Cell Phone: (_____) _______________________
5. Date of Birth: __________________
6. Birthplace: City____________________________ County_____________________ State______________
7. Please Check: □ MALE □ FEMALE
U.S. Citizen: □ YES □ NO If No, please state country of citizenship: ___________________
Permanent Resident: □ YES □ NO New Jersey Resident: □ YES □ No
8. Marital Status: □ Single □ Married □ Divorced □ Separated
9. Ethnic/Racial Self-Description: ____________________________________________
10. Do you have a physical disability that requires specially designed instructional materials or programs, modified
physical facilities, or related services to enable full participation in and access to the PREP program at
UMDNJ-SOM? □ NO □ YES (please explain) ______________________________________________
11. Father’s/Guardian’s Name __________________________ Phone (___) _____________
12. Address: Street _______________________City ______________ State ____ Zip _____
13. Occupation _____________________________________________________________
14. Mother’s/Guardian’s Name _________________________ Phone (___) _____________
15. Address: Street _______________________City_______________ State ____Zip_____
16. Occupation _____________________________________________________________
17. Education Level: Father _____________________ Mother _______________________
18. How many siblings do you have? ____________________
19. Please list their ages: _____________________________________________________
20. Did any of them attend college: ______No ______Yes If Yes, please indicate the college(s) below:
Educational Information
21. What educational institution are you presently attending? ___________________________________________
22. Are you a participant in your school’s Educational Opportunity Fund (EOF) program? Check: □ YES □ NO
23. What year are you in school? ________________________________ GPA (cumulative)____________
24. What is your Major? _________________________________ Minor: ____________________________
25. List courses you are currently enrolled in:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
26. List any extracurricular activities you participate in (sports, hobbies, clubs, etc.):
_____________________________________________________________________
_____________________________________________________________________
27. Do you have an advisor? ____No _____Yes If Yes, please indicate the person’s name and title:
_____________________________________________________________________________________
28. How did you learn about the PREP program? ________________________________________________
29. Have you ever participated in a summer enrichment program? _____No _____Yes If Yes, indicate the
name and location of the program: ___________________________________________________________
30. List names, addresses and titles or occupations of two persons you have asked to complete the recommendation
forms you received with your application:
Name ____________________________ Title or Occupation ______________________
Address _________________________________________________________________
Name ____________________________ Title or Occupation ______________________
Address _________________________________________________________________
31. Please write a short narrative on a separate sheet of paper in which you introduce yourself. Explain your
interest in medicine, why you want to participate in the Summer PREP program, and why you would make an
excellent participant.
I certify that the above information is complete and true to the best of my knowledge.
Your Signature ______________________________________________ Date ___________________________
Please return to: Summer PREP Program
UMDNJ - School of Osteopathic Medicine
Academic Center, Suite 210
One Medical Center Drive
Stratford, NJ 08084
Phone: 856-566-6196
Fax: 856-566-6341
The UMDNJ - School of Osteopathic Medicine
2009 Summer Pre-Medical Research Education Program (PREP)
Academic Center, Suite 210
One Medical Center Drive
Stratford, NJ 08084
RECOMMENDATION FORM
INSTRUCTIONS:
This form must be completed by a pre-medical advisor, academic advisor, or science faculty
member. Please have the individual completing this form return it directly to the above address.
The applicant must sign this form below before giving it to the recommender for completion under
the provision of the Family Education Rights and Privacy Act (Buckley Act).
I waive any right of access that I might have to this recommendation form.
Applicant's Signature and Date
I do not waive any right of access that I might have to this recommendation form.
Applicant's Signature and Date
Full Name of Applicant:
Last First Middle
Evaluator: Please give your candid assessment of this applicant. Feel free to attach a letter in
addition to the checklist provided. Specific descriptions of the individual's strengths and
weaknesses are most valuable to the Selection Committee. Responses to the following questions
can also assist the selection process: Does the applicant possess the academic potential for pursuit of
medical studies? How would you rate the applicant’s potential versus other students you have
worked with? What personal characteristics of this applicant make her/him an outstanding
candidate for the PREP program? Thank you for your participation in our evaluation process!
Please use checkmarks in the table below to rate the applicant according to your observation
or knowledge.
Outstanding Excellent Satisfactory Fair Poor No knowledge
or opportunity
to observe
Academic Performance
Class Preparedness/Attendance
Effort & Perseverance
Self motivation
Handles counseling or critique
Communications Skills
(verbal & written)
Teamwork/Ability to work with others
Aptitude for a career in clinical medicine or bio-medical research
Judgment/Maturity
Facility w/ computers, laboratory equipment, etc.
Contributes to school/department community
Leadership skills
Intellectual curiosity/ability
Analytical/ problem-solving skills
In what capacity have you known this student? __________________________________________
How long have you known this student? _______________________________________________
Printed name of person completing recommendation:_____________________________________
Title:____________________________________________________________________________
Institution: _______________________________________________________________________
Signature: _______________________________________________________________________
Date: ___________________________________________________________________________
The UMDNJ - School of Osteopathic Medicine
2009 Summer Pre-Medical Research Education Program (PREP)
Academic Center, Suite 210
One Medical Center Drive
Stratford, NJ 08084
RECOMMENDATION FORM
INSTRUCTIONS:
This form must be completed by a pre-medical advisor, academic advisor, or science faculty
member. Please have the individual completing this form return it directly to the above address.
The applicant must sign this form below before giving it to the recommender for completion under
the provision of the Family Education Rights and Privacy Act (Buckley Act).
I waive any right of access that I might have to this recommendation form.
Applicant's Signature and Date
I do not waive any right of access that I might have to this recommendation form.
Applicant's Signature and Date
Full Name of Applicant:
Last First Middle
Evaluator: Please give your candid assessment of this applicant. Feel free to attach a letter in
addition to the checklist provided. Specific descriptions of the individual's strengths and
weaknesses are most valuable to the Selection Committee. Responses to the following questions
can also assist the selection process: Does the applicant possess the academic potential for pursuit of
medical studies? How would you rate the applicant’s potential versus other students you have
worked with? What personal characteristics of this applicant make her/him an outstanding
candidate for the PREP program? Thank you for your participation in our evaluation process!
Please use checkmarks in the table below to rate the student according to your observation or
knowledge.
Outstanding Excellent Satisfactory Fair Poor No knowledge
or opportunity
to observe
Academic Performance
Attendance/Class Preparedness
Effort & Perseverance
Self-motivation
Handles counseling or critique
Communications Skills
(verbal & written)
Teamwork/Ability to work with others
Aptitude for a career in clinical medicine or bio-medical research
Judgment/ Maturity
Facility with computers, laboratory equipment, etc.
Contributes to school/department community
Leadership skills
Intellectual curiosity/ability
Analytical/problem-solving skills
In what capacity have you known the applicant? ________________________________________
How long have you known the applicant? _____________________________________________
Printed name of person completing the recommendation:__________________________________
Title:____________________________________________________________________________
Institution: _______________________________________________________________________
Signature: _______________________________________________________________________
Date: ___________________________________________________________________________
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