Student Information

Name (Last, First, Middle):         Gender:  None Selected Male Female   

U.S. Citizen               Resident                 Alien #                             

Current Mailing Address:        

City:            State:            Zip Code:  

Phone Number:

Social Security Number:       Ethnicity: None Selected American Indian, Alaskan Native Black/African American White (not of Hispanic origin) Hispanic American Asian/ Pacific Islander Other

 Email:        If Other please specify

 Academic Information

College/University: 

Address:

 Academic Year:     None Selected Freshman Sophomore Junior

Current Major:       Minor: 

Current, Overall grade point average:        Major GPA: 

Expected date of Graduation:       

Plans for Graduate Study:  None Selected Yes No Not Sure          Degree Objectives: None Selected Master's Ph.D. M.D. M.D./Ph.D. Other

Graduate/ Professional Interest:

Professional References

Please provide names and contact numbers of three persons who will be writing letters of recommendation for you.

Statement of Purpose

Please describe your interest in participating in the FIU RISE Program. Include a description 
of any research experience you have had and your personal and educational goals.