EmailMe Form - Biology Fellows Program Academic Year 2016/17

PERSONAL INFORMATION

Full Name *

First Last

Permanent Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Contact Phone Number *

### - ### - ####

Berkeley Email *

Alternate Email *

Student ID *

Birthdate *

MM / DD / YYYY

Last 4 Digits of SSN: *

If you do not have a SSN, please just fill in "0000"

Gender

Ethnic Category: *

This information is used for BFP grant reporting.

Ethnicity:

(e.g. Chinese, Vietnamese, Mexican, Colombian, etc. or decline to state)

What is the highest level of education attained by your parent/guardian #1? *

What is the highest level of education attained by your parent/guardian #2?

Are You From a Disadvantaged Background? *

Yes

No

Decline to state

Definitions of disadvantaged status, meet either criterion (A or B) listed below. These guidelines are from the NIH.

A. Individuals who come from a family with an annual income below established low-income thresholds. These thresholds are based on family size, published by the U.S. Bureau of the Census; adjusted annually for changes in the Consumer Price Index; and adjusted by the Secretary for use in all health professions programs. The Secretary periodically publishes these income levels at http://aspe.hhs.gov/poverty/index.shtml. For individuals from low-income backgrounds, the institution must be able to demonstrate that such candidates (a) have qualified for Federal disadvantaged assistance; or (b) have received any of the following student loans: Health Professional Student Loans (HPSL), Loans for Disadvantaged Student Program; or (c) have received scholarships from the U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need.

B. Individuals who come from a social, cultural, or educational environment such as that found in certain rural or inner-city environments that have demonstrably and recently directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a research career.

ACADEMIC INFORMATION

Undergraduate Status: *

UC GPA: *

(Transfer GPA if applicable)

Are you a transfer student? *

Yes

No

If you answered yes to the question above, please list your transfer institution. Otherwise, type n/a. *

Anticipated Semester and Year of Graduation: *

Have you declared a major? *

Yes

No

List your intended/declared major: *

If you are a DECLARED DOUBLE MAJOR, please list both majors

Are you intending to complete an honors thesis this coming academic year? *

Yes

No

Please indicate any campus employment you will have during Fall 2015/Spring 2017: *

RESEARCH INTERESTS AND HISTORY

List any prior research experience. Please include dates of participation, the name of the PI, location of research (name of institution/hospital), and a brief description of your project or role in a research project (no more than 5 sentences). Be sure to indicate if any of this research was funded by a previous BFP or CNR-BSP award. *

Please type n/a if you have not done any previous research experience

Have you previously applied to BFP? *

Yes

No

If you have applied to BFP, list the semester(s) and year(s) you applied.

Have you previously been awarded BFP? *

Yes

No

If you’ve previously been awarded BFP, list the semester(s) and year(s) of the award.

If you know which laboratory you will be working in during academic year 2016-2017:

List the name of the Principal Investigator:

The email of the Principal Investigator:

The principal investigator's lab is located at (name of institution):

UCSF, UCB, CHORI, etc.

Title and brief description of your research project (100 word max):

If you have not already arranged to do research in a laboratory for 2016-2017 academic year:

List the names, locations (e.g. UCB, UCSF, etc.) and email addresses of up to 3 faculty members you would like to do research with.

Describe any contact you have made with these faculty members (initial meetings, emailed, etc.).

Please note, if you are awarded BFP you must find a lab by August 17th or you will have to forfeit your award.

LETTERS OF RECOMMENDATION - PLEASE READ

You should have two letters of recommendation sent to our offices BY THE DUE DATE. They MUST be emailed to bfpletters@berkeley.edu as a PDF attachment, not in the body of the email. The letter must be sent by the letter writer and not you, the applicant.

List the names and contact information for the people who will be providing your letters of recommendation.

NOTE: If you are a previous BFP awardee or are currently working in a laboratory and want to continue your research there, one of your letters must be from your research supervisor/PI and should include your progress and involvement with the project.

Full Name of Recommender #1 *

Email of recommender #1 *

Full Name of Recommender #2 *

Email of recommender #2 *

STATEMENT OF PURPOSE AND OTHER UPLOADED INFORMATION

Please type your statements in Microsoft Word (or the word processor of your choice) and copy and paste the text into the boxes provided so that you have a copy of your submitted work.

Statement of Purpose (700 word limit)

Within the given word limit address the following questions/prompts:
*Why are you interested in pursuing research?
*What are your potential future career goals and how does research fit into these goals and your interests? (Please be specific about how you think being in BFP will benefit you)
*If you are already in a lab, briefly describe the project, your role, and how the project fits in with your research interests and overall goals.
*If you do not have a lab/project already, briefly describe how your research interests fit in with the research being conducted in the labs of the faculty member(s) you identified as wanting to work with. *

FINANCIAL AID INFORMATION (OPTIONAL)

MyFinAid report and Statement of financial need are both optional, but strongly encouraged.

Please describe in the space provided below any financial need you have that limits your ability to conduct unfunded research (500 word limit).

MyFinAid Report (PDF of UC Berkeley financial aid offer)

Upload PDF ONLY - Here is a site that details how to convert various types of documents to PDFs: http://www.wikihow.com/Convert-a-Microsoft-Word-Document-to-PDF-Format

Unofficial Transcripts *

Please upload only PDFs of all coursework you have completed since graduating from high school.

Here is a site that details how to convert various types of documents to PDFs: http://www.wikihow.com/Convert-a-Microsoft-Word-Document-to-PDF-Format

Resume *

Upload PDF ONLY - Here is a site that details how to convert various types of documents to PDFs: http://www.wikihow.com/Convert-a-Microsoft-Word-Document-to-PDF-Format

SIGNING STATEMENT

By electronically signing my name below I indicate that all the information is complete, factually correct and honestly presented. I understand that if this representation is not correct, the Biology Fellows Program reserves the right to withdraw my application from consideration. I also authorize the Biology Fellows Program staff to access my student records.

If I am selected as a Biology Fellow Program Participant, I authorize BFP staff to monitor my academic performance. I also agree to comply with all of the requirements of the program and understand that continued participation is dependent upon satisfactory program participation.

After my participation in the Biology Fellows Program, I agree to maintain contact with BSP/BFP staff to enable them to track my career development in order to evaluate the outcomes of the BFP program. Furthermore, I agree to allow the Biology Scholars Program to share this information with the Howard Hughes Medical Institute and any other funders.

I certify that information contained in this application is true and complete.

Electronic Signature *

Today's Date *

MM / DD / YYYY

If you have program questions or need more information, please contact:
Sabriya N. Rosemond, Ph.D. – srosemond@berkeley.edu, 2022 VLSB, 510-643-4746