Student Information

Name (Last, First, Middle):        

Gender:     Male Female

U.S. Citizen               Resident       Alien # 

Current Mailing Address:      

City:     State:      Zip Code:  

Phone Number:

Panther ID#:      

Ethnicity (Must select one):

Primary Email:         

Secondary Email:

 Academic Information

College/University: 

Address:

Address:

City: State: Zip:

Academic Year:     Please select... Freshman Sophomore Junior Senior Graduate Student

Applying for:    RISE Undergraduate    RISE Graduate Program

Current Major:      

Minor: 

Current, overall grade point average:       

Expected date of Graduation: Term Fall 2009 Spring 2010 Summer 2010 Fall 2010 Spring 2011 Summer 2011 Fall 2011 Spring 2012 Summer 2012 Fall 2012 Spring 2013 Summer 2013 Fall 2013 Spring 2014 Summer 2014 Fall 2014 Spring 2015 Other             

Degree Objectives: Please select... B.A. B.S. B.Sc. Master's Ph.D. M.D. M.D./Ph.D. DDS DMD DVM DO OD Pharm D Other

Graduate/ Professional Interest:

Applied to Graduate program?      Yes      No

When:            Where:

GRE SCORE:

aLL aPPLICANTS MUST PROVIDE THE FOLLOWING:

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.

ReSEARCH EXPERIENCE

ONLY IF APPLICABLE

Please list University, Mentor, Research Topic and Start/End date

IMPORTANT

In order to be considered, applications must be completely filled and submitted before the deadline date.