Carolinas Medical Center - Atrium Health
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Carolinas HealthCare System
Summer Student Research Program
Application [rev. 11/13]
Contact
Information
Name ,
Last, First MI
Current Street
Mailing City, State, Zip
Address Address Valid until (mm/yyyy) Permanent Residence
Phone number ( ) -
E-mail address
Undergraduate
Institution
Graduate Institution
(if applicable)
School
Major (if declared)
Expected graduation date (mm/yyyy):
GPA: overall: science/math:
School
Major
Expected graduation date (mm/yyyy)
GPA: overall
Biographical Information
Gender: male female
Date of Birth (mm/dd/yyyy)
Country of residence
Country of citizenship
Are you a U.S. citizen? Yes No
If no, do you have permanent resident status? Yes No
I-551 card number:
Ethnicity/Race:
Fluent (spoken and written) in any other language aside from English?
Please list
Please send (1) a copy of a transcript from each college/university attended, (2) 3 letters of reference and (3) a completed application by mail or e-mail to:
Jon Beni (Jon.Beni@)
Research Office Building, 5th floor
P.O. Box 32861
Charlotte, NC 28232
|Letters will be| |Name |Title |E-mail |Phone |
|sent by: | | | | | |
| |1 | | | | |
| |2 | | | | |
| |3 | | | | |
Honors / Accomplishments / Experience
Please list academic honors, memberships, accomplishments, and relevant experiences (e.g. previous work in the lab and/or clinic) with corresponding year(s) of involvement. Do not send a Resume as a substitute for this section.
Research Interests
In order of descending preference, please list the laboratories/research units in which you are most interested. (see website for available unit specialties)
1.
2.
3.
4.
5.
Personal Statement
Please describe your career goals and how you believe this program will help you accomplish those goals. (700 word maximum)
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