The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Research Education Program for Minority Medical Students

Returning?

A A A

1. Please complete the following information for the Research Education Program for Minority Medical Students

2. Project information must be completed with your mentor.

3. Your mentor must complete and sign the verification section.

4. This application will close on Friday November 8, 2019 at 6 pm.

First Name

* must provide value

Last Name

* must provide value

Middle Initial. Enter NMN if you have no middle name.

* must provide value

Address: List your complete address to include:
Resident number and apartment number if applicable.
Street name, City, State, and Zip Code

* must provide value

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Phone number beginning with area code.

* must provide value

E-mail

* must provide value

Alternate e-mail - must be different from your school e-mail.

* must provide value

Gender

* must provide value

Male

Female

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Date of birth

* must provide value

Y-M-D

Age

* must provide value

Race

* must provide value

Ethnicity

* must provide value

Hispanic or Latino

NOT Hispanic or Latino

Do not wish to provide

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Minority

* must provide value

Yes

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US Citizen

* must provide value

Yes

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List the country of your citizenship

* must provide value

Expected date of graduation

* must provide value

Y-M-D

List your undergraduate College/University

* must provide value

Undergraduate major

* must provide value

Date of undergraduate graduation

* must provide value

M-D-Y

Do you have research experience? Prior research experience is not required for acceptance into the program

* must provide value

Yes

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Attach a PDF document describing your research experience.

* must provide value

Upload file

Mentor's Full Name

* must provide value

Mentor's Department

* must provide value

Mentor's Title

* must provide value

Mentor's Email address

* must provide value

Project Title

* must provide value

Attach a PDF document explaining the Aims, which are the overall goal or what you hope to achieve at the end of the project. Please include a statement describing the relevance of the project to cardiovascular function and/or disease.

* must provide value

Upload file

Attach a PDF document describing the Objectives of your project. The objectives list the steps that will be taken to achieve the desired outcome.

* must provide value

Upload file

Mentor's Name

* must provide value

Mentor's E-mail

* must provide value

Name of the student you will mentor

* must provide value

Have you agreed to mentor this applicant during the 13 week Flex phase from March 9, 2020 to June 5, 2020?

* must provide value

Yes

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Mentor's Signature - The application is not valid without the mentor's signature.

Click on the "Add signature" link and use your mouse to sign this form.

* must provide value

Add signature

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