Personal Information

First Name *

Middle Name/Initial 

Last Name *

Social Security Number * 

  (xxx-xxx-xxxx)

Current Address

Street *

City *

State *

Zip *

At this address until *

Phone (Daytime) * 

  (xxx-xxx-xxxx)

Phone (Evening) * 

  (xxx-xxx-xxxx)

E-mail Address

Date of Birth * 

  (dd/mm/yyyy)

Texas Resident *

  Please select one. Yes No

Sex *

  Please select one. Female Male

Citizenship *

USA

  Please select one. Yes No

If not a US Citizen, 
type of Visa

Permanent Address

Street *

City *

State *

Zip *

Home Phone Number 

  (xxx-xxx-xxxx)

Education

Current Institution *

Location (City, State) *

Dates Attended: From *

Dates Attended: To *

Major *

Minor

GPA *

Math/Science GPA

List of Math and Science Coursework (Title, Hours, and Grade)

Expected Date of Graduation *

Year in School *

  Please select one. Freshman Sophomore Junior Senior

Names of one faculty member and one advisor who you asked to provide a letter of recommendation

Please have the letters mailed to:
The Graduate School of Biomedical Sciences
Attn: SURP
The University of Texas Medical Branch
301 University Blvd.
Galveston, TX 77555-1050

Previous Institution

Location (City, State)

Dates Attended: From

Dates Attended: To

Major

Minor

GPA

If you are considering a PhD, MD, or MD/PhD degree, please answer the following questions.

Statement of Career Goals: What degree will you seek as a postgraduate? *

  Please select one. Ph.D. M.D. M.D.-Ph.D. Other

If you consider a Ph.D. degree (skip if not applicable):

Would you consider a Graduate School in Texas?     Yes  No

Would you consider the Graduate School of Biomedical Science of UTMB in Galveston?     Yes  No

If you consider a M.D. degree (skip if not applicable):

Would you consider a Medical School in Texas?     Yes  No

Would you consider the Medical School of UTMB in Galveston?     Yes  No

If you consider a M.D./Ph.D. degree (skip if not applicable)::

Would you consider a M.D./Ph.D. Program in Texas?     Yes  No

Would you consider the M.D./Ph.D. Program of UTMB in Galveston?     Yes  No

Please describe what you hope to gain through your participation in the UTMB Summer Undergraduate Research Program.  (No longer than 200 words.) ***

Please describe what you consider the most significant scientific advance you have read or heard about in the last year.
(No longer than 100 words.)*

If a GRE course is offered during the summer, will you take it? 

Please select one. Yes No

Will you pay the $25.00 registration fee to hold a place for the GRE course?

Please select one. Yes No

Are you interested in computer modeling?

Please select one. Yes No

Do you have an engineering, physical science or inorganic chemistry background/major?

Please select one. Yes No

Do you have a computer science background?

Please select one. Yes No

Would you prefer a data analysis experience?

Please select one. Yes No

Would you prefer a bench science experience?

Please select one. Yes No

Would you work in a lab that uses animals or animal products?

Please select one. Yes No

Would you prefer an experience that generates data from interviews?

Please select one. Yes No

Have you had previous research experience?

Please select one. Yes No

If yes, topic and length of experience.

Please rank the top five research topics that interest you in order of preference, with the first being the topic of highest interest (i.e. a topic that you would like to be involved in during the summer).

Please select your 1st choice. Bioethics Biostatistics and Epidemiology Cancer Biology and Carcinogenesis Cellular Physiology, Signal Transduction, and Hormone Genetic and Environmental Toxicology, Mutagenesis DNA Healing Dimensions, Environment, and Healing Practices Health Behavior and Socio-Medical Sciences Health Interventions, Education, and Promotion Health Outcomes, Clinical Gerontology, and Rehabilitation Humanities in Medicine and Health Care Immunology and Host Defense Marine Biology and Mariculture Microbial and Viral Pathogenesis and Infectious Diseases Molecular Biology and Genetics Neural Injury, Regeneration, Repair, and Pain Neurobiology and Neuropharmacology Pathobiology Structure and Function of Macromolecules Traditional and Emergent Nursing Interventions Tropical and Emerging Diseases Development, Nutrition, Reproduction, and Aging Other, Please Specify

Please select your 2nd choice. Bioethics Biostatistics and Epidemiology Cancer Biology and Carcinogenesis Cellular Physiology, Signal Transduction, and Hormone Genetic and Environmental Toxicology, Mutagenesis DNA Healing Dimensions, Environment, and Healing Practices Health Behavior and Socio-Medical Sciences Health Interventions, Education, and Promotion Health Outcomes, Clinical Gerontology, and Rehabilitation Humanities in Medicine and Health Care Immunology and Host Defense Marine Biology and Mariculture Microbial and Viral Pathogenesis and Infectious Diseases Molecular Biology and Genetics Neural Injury, Regeneration, Repair, and Pain Neurobiology and Neuropharmacology Pathobiology Structure and Function of Macromolecules Traditional and Emergent Nursing Interventions Tropical and Emerging Diseases Development, Nutrition, Reproduction, and Aging Other, Please Specify

Please select your 3rd choice. Bioethics Biostatistics and Epidemiology Cancer Biology and Carcinogenesis Cellular Physiology, Signal Transduction, and Hormone Genetic and Environmental Toxicology, Mutagenesis DNA Healing Dimensions, Environment, and Healing Practices Health Behavior and Socio-Medical Sciences Health Interventions, Education, and Promotion Health Outcomes, Clinical Gerontology, and Rehabilitation Humanities in Medicine and Health Care Immunology and Host Defense Marine Biology and Mariculture Microbial and Viral Pathogenesis and Infectious Diseases Molecular Biology and Genetics Neural Injury, Regeneration, Repair, and Pain Neurobiology and Neuropharmacology Pathobiology Structure and Function of Macromolecules Traditional and Emergent Nursing Interventions Tropical and Emerging Diseases Development, Nutrition, Reproduction, and Aging Other, Please Specify

Please select your 4th choice. Bioethics Biostatistics and Epidemiology Cancer Biology and Carcinogenesis Cellular Physiology, Signal Transduction, and Hormone Genetic and Environmental Toxicology, Mutagenesis DNA Healing Dimensions, Environment, and Healing Practices Health Behavior and Socio-Medical Sciences Health Interventions, Education, and Promotion Health Outcomes, Clinical Gerontology, and Rehabilitation Humanities in Medicine and Health Care Immunology and Host Defense Marine Biology and Mariculture Microbial and Viral Pathogenesis and Infectious Diseases Molecular Biology and Genetics Neural Injury, Regeneration, Repair, and Pain Neurobiology and Neuropharmacology Pathobiology Structure and Function of Macromolecules Traditional and Emergent Nursing Interventions Tropical and Emerging Diseases Development, Nutrition, Reproduction, and Aging Other, Please Specify

Please select your 5th choice. Bioethics Biostatistics and Epidemiology Cancer Biology and Carcinogenesis Cellular Physiology, Signal Transduction, and Hormone Genetic and Environmental Toxicology, Mutagenesis DNA Healing Dimensions, Environment, and Healing Practices Health Behavior and Socio-Medical Sciences Health Interventions, Education, and Promotion Health Outcomes, Clinical Gerontology, and Rehabilitation Humanities in Medicine and Health Care Immunology and Host Defense Marine Biology and Mariculture Microbial and Viral Pathogenesis and Infectious Diseases Molecular Biology and Genetics Neural Injury, Regeneration, Repair, and Pain Neurobiology and Neuropharmacology Pathobiology Structure and Function of Macromolecules Traditional and Emergent Nursing Interventions Tropical and Emerging Diseases Development, Nutrition, Reproduction, and Aging Other, Please Specify

Other

Are you related to anyone enrolled or working at UTMB?

Please select one. Yes No

Who referred you to UTMB?

Ethnic Origin
Please note: The remaining information is not required, but when provided it allows UTMB to respond to the record keeping provisions of various laws.  If provided, it will not be provided to those making the admission decision, and it will not in any way effect the consideration of your application.

UTMB is subject to federal regulations concerning equal opportunity and affirmative action.  UTMB does not discriminate against applicants or students on the basis of race, color, national origin, religion, sex, age, disability, sexual orientation, or status as a Vietnam veteran.  Reasonable accommodation, based on disability or religious observances, will be considered when appropriate.

Please select one. American Indian or Alaskan Native Asian or Pacific Islander African-American Hispanic White Other

Programs you have participated in

If applicable, please select one. MARC Honors Undergraduate Program MBRS Program