NEI PRE-DOCTORAL (T35) SUMMER RESEARCH FELLOWSHIPS FOR OPTOMETRY STUDENTS

This application must be submitted online. Please follow the instructions carefully.
Date you wish to enroll:

Summer
(year)
Personal Information
First Name*
Last Name*
Middle Name
Social Security Number
(###-##-####)
Date of Birth*
(mm/dd/yyyy)
Phone*
Secondary Phone
Email*
Permanent Address
Address 1*
Address 2
City**
State/Province*
Zip*
Present Address (If different than permanent address)
Address 1
Address 2
City
State/Province
Zip
Do you have U.S. Citizenship?*

YesNo
Are you a U.S. Permanent Resident?*

YesNo
Education
College*
Date From*
(mm/yyyy)
Date To*
(mm/yyyy)
Degree*
Year*
(mm/yyyy)
Major*
Grade Point Average*
Add Additional Education
College
Date From
(mm/yyyy)
Date To
(mm/yyyy)
Degree
Year
(mm/yyyy)
Major
Grade Point Average
Add Additional Education
College
Date From
(mm/yyyy)
Date To
(mm/yyyy)
Degree
Year
(mm/yyyy)
Major
Grade Point Average
Add Additional Education
College
Date From
(mm/yyyy)
Date To
(mm/yyyy)
Degree
Year
(mm/yyyy)
Major
Grade Point Average
Letters of Recommendation
Two letters of recommendation should be emailed as a PDF file to baizin@sunyopt.edu.

Please type your recommender's details below. You must have two.
Name*
Title*
Email*
Associated College/University*
Name*
Title*
Email*
Associated College/University*
Additional Information
In 250 words or less, describe why you are interested in this program and how it fits in with your long term career goals:
List any special skills you have (e.g. computers, languages) that could be applicable to research:
Research Mentors will be assigned to admitted applicants. Please indicate 3 Mentors you would be interested in working with:
Research Mentors will be assigned to admitted applicants. Please indicate 3 Mentors you would be interested in working with:1st Choice:
2nd Choice:
3rd Choice:
I hereby certify that, to the best of my knowledge, the above information is complete and accurate.
(type your initials here)*
Check the box to confirm you're not a robot*
Should be Empty:

Personal Information

Permanent Address

Present Address (If different than permanent address)

Education

Letters of Recommendation

Additional Information