EMSOP SURF Application Form

Please fill out this form to be considered for the Summer Undergraduate Research Fellowship (SURF) Program. Applications must be submitted electronically by February 1, 2018.
CONTACT INFORMATION
Full Name*

First NameLast Name
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Campus Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
University E-mail Address*
Personal Email Address*
Do you have housing for the entire 10-week SURF Program?*

YesNo
UNIVERSITY. Students must be enrolled at a U.S. university or college for the Fall 2016 semester.
University/College*
Current Year*
Major*
Cumulative GPA*
Expected Graduation Date*
Year
Are you currently enrolled in the Rutgers PharmD Honors Program?*

YesNo
Do you have any previous research experience? If you answered yes, please answer the following questions:*

YesNo
How long have you participated in research?
Did you work on a laboratory or clinical project?

LaboratoryClinical
Where did you perform this research (name of institution)?
Who was your research mentor?
LETTER(S) OF RECOMMENDATION
Only 1 letter of recommendation is required. This letter must be from a professor or research

advisor who is familiar with your work. If you have made arrangements to work with a specific research mentor, then they need to submit your letter of recommendation. A second letter of recommendation can be included but is not required. Please list the name, position, phone number, and email address of each person that will provide a letter of recommendation. All letters should be uploaded to the link on the webpage by the deadline.
Full Name*

First NameLast Name
Title or Position*
Phone Number*

Area CodePhone Number
E-mail Address*
Full Name

First NameLast Name
Title or Position
Phone Number

Area CodePhone Number
Email Address
SUMMER FELLOWSHIP
Have you previously applied to the SURF Program?*

YesNo
Have you previously participated in the SURF Program?*

YesNo
RESEARCH AREAS
SURF students perform their research in 6 different areas (Pharmacology and Toxicology, Environmental Health Sciences, Pharmaceutics, Chemical Biology, Pharmacy Practice, Medicinal Chemistry). Please select your top 3 choices of research areas.
What is your first choice?*
Second choice?*
Third choice?
RESEARCH MENTOR
Has a professor agreed to serve as your mentor for the SURF Program?*

YesNo
If yes, please indicate the professor's name.
CAREER GOALS
Which best describes your career goals? More than 1 option can be selected.*

Ph.D. degreeM.D. degreePharm.D. degreeM.S. or M.P.H. degreePost-Graduate FellowshipPost-Graduate ResidencyOther
DEMOGRAPHIC INFORMATION
This information is used only for federal reporting and is not part of the application process. However, your participation is greatly appreciated to ensure continued funding.
Gender

MaleFemale
Year of Birth
Year
Are you Hispanic or Latino?

YesNo
Race
If other, please specify:
Citizenship*

US CitizenPermanent ResidentOther
Are you the first in your family to attend college (4 year degree)?

YesNo
Do you have a disability?

YesNo
EMERGENCY CONTACT INFORMATION
Full Name*

First NameLast Name
Relationship to Applicant
Phone Number*

Area CodePhone Number
RESUME/CV & PERSONAL STATEMENT
Please upload your resume/CV (3 pages maximum) along with your personal statement explaining why you are applying for this program. The statement should be limited to 1 page (single-spaced). Please indicate:

-Your career plans after college including plans for graduate or post-graduate study

-What you hope to gain from this experience and how it will advance your career goals

-Previous relevant work or research experience, honors, awards, or academic accomplishments

-If you are requesting participation for a second summer, please describe specifically how you will benefit from a second summer.
Upload personal statement as a .pdf file.*

Upload a File

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Upload resume/CV as a .pdf file.*

Upload a File

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Upload transcripts as a .pdf file.*

Upload a File

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Signature*
Date*

MonthDayYear
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CONTACT INFORMATION

UNIVERSITY. Students must be enrolled at a U.S. university or college for the Fall 2016 semester.

LETTER(S) OF RECOMMENDATION

SUMMER FELLOWSHIP

RESEARCH AREAS

RESEARCH MENTOR

CAREER GOALS

DEMOGRAPHIC INFORMATION

EMERGENCY CONTACT INFORMATION

RESUME/CV & PERSONAL STATEMENT