NIDDK

Pacific Island Summer Internship Program - High School Application

All fields marked with a * are required for Final Submission.
1. Personal Information  
*First Name:
Middle Initial:
*Last Name:
*(Permanent Mailing Address) Street 1:
(Permanent Mailing Address) Street 2:
*(Permanent Mailing Address) City:
*(Permanent Mailing Address) State:     if not listed, please enter here: 
*(Permanent Mailing Address) Zip Code:
*Home Phone:
*Cell Phone:
Email Address:
*Are you a U.S. Citizen: Yes   No
*If no, are you a permanent resident: Yes   No
(Photographic copies of both sides of your Permanent Residency Card are required prior to acceptance to the Program. )
   
2. Parent or Guardian Contact Information
*Title:
*First Name:
Middle Initial:
*Last: Name:
*(Permanent Mailing Address) Street 1:
(Permanent Mailing Address) Street 2:
*(Permanent Mailing Address) City:
*(Permanent Mailing Address) State:     if not listed, please enter here: 
*(Permanent Mailing Address) Zip Code:
*Home Phone:
Work Phone:
*Cell Phone:
Email Address:
   
3. Demographic Information
*Date of Birth: Click Here to Pick a Date
Gender:
*Pacific Islander: Yes   No
*If yes above, your nationality:
If Other Nationality, please specify:
*Race:
If Other Race, please specify:
   
4. Family Income
ONLY Individuals who are applying to the PI/AN Intern Program based upon coming from a disadvantaged background* are required to complete the following section. This information is not based upon your own current financial status.
*Are you applying based only
on disadvantaged background:
(If yes, next 2 questions are required)		 Yes   No
*Annual Total household income:
*Total number living in household
including you:
*Individuals from disadvantaged backgrounds are defined as: 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.
   
5. Academic Information
(An official current high school or college transcript is required and should be sent from your school to the address at the end of the application)
High School Name:
Current Grade:
High School Address - For High School Students Only
Street 1:
Street 2:
City:
State:     if not listed, please enter here: 
Zip Code:
   
Previous High School Attended (if any):
Date Attended:
Grade:
Street 1:
Street 2:
City:
State:     if not listed, please enter here: 
Zip Code:
   
Cumulative GPA:
Current Grading Scale:
(i.e. 4.0, 5.0, other (please specify))
   
5A. Employment or Volunteer Experience

Employment or Volunteer Experience

 Brief description
   
5B. Honors and Awards      
Brief description Month Year
   
5C. Extra Curricular Activities
(List all activities such as clubs, sports, memberships, student government etc., and provide a brief description of each.)
Extra Curricular Activity Description
   
6. References: (Two Letters of Recommendation are required from individuals who are familiar with your academic abilities and accomplishments. Please have the individual writing your recommendation submit a signed letter directly to the email address, mailing address or fax below.
Recommendation 1  
A letter of recommendation will be expected from...
*Title:
*First Name:
Middle Initial:
*Last: Name:
*(Permanent Mailing Address) Street 1:
(Permanent Mailing Address) Street 2:
*(Permanent Mailing Address) City:
*(Permanent Mailing Address) State:     if not listed, please enter here: 
*(Permanent Mailing Address) Zip Code:
*Phone:
Fax:
Email Address:
   
Recommendation 2  
A letter of recommendation will be expected from...
*Title:
*First Name:
Middle Initial:
*Last: Name:
*(Permanent Mailing Address) Street 1:
(Permanent Mailing Address) Street 2:
*(Permanent Mailing Address) City:
*(Permanent Mailing Address) State:     if not listed, please enter here: 
*(Permanent Mailing Address) Zip Code:
*Phone:
Fax:
Email Address:
   
7. *Personal Statement: Please state your research interest and long-term career goals, if known, and reasons for applying to the PI/AN Intern Program. What are your expectations for your summer research training experience, and what do you hope to gain by participating in this program? If more space is needed please attach a separate sheet. (600 words or less)
COUNT YOUR WORDS!

Characters left.
   

NOTICE TO ALL APPLICANTS

  • Students are advised to ensure that all application information is accurate. False or inaccurate information contained in this application may be grounds for denying your candidacy or removing you from the program.
  • Deadline for applications is February 15. However, we encourage applicants to submit their applications ASAP.
  • Additional information for payroll purposes may be requested upon selection.
  • An official academic transcript should be requested at least one month in advance and mailed by your school directly to the address below. Alternatively, you may submit your official transcript in the original envelope which was sealed by the appropriate school official along with you application.
  • Students should request Letters of Recommendation at least one month in advance to insure timely completion and receipt of the letter. The recommendation provider should mail the letter to the address indicated below. Please download the Letter of Recommendation template.
  • Applications and Letters of Recommendation may be mailed, submitted electronically, or via fax to:

    PI/AN Intern Program
    Winnie Martinez
    Program Analyst
    Office of Minority Health Research Coordination
    II Democracy Plaza, Room 906A
    6707 Democracy Blvd.
    Bethesda, MD 20892-5454
    TEL:  (301) 435-2988
    FAX:  (301) 594-9358
    EMAIL: martinezw@mail.nih.gov

  • The receipt of your completed application package will be acknowledged via email.



You can save your information and come back later to complete and finalize using your login and password. One you press the Submit Final Application button, the application will be forwarded to the review committee and you will be unable to make changes. Remember your login and password are case-sensitive and are only required if you are not ready to submit your Final Application.
*Login:
*Password:
AGREEMENT:  I understand that electronic submission of this application to the NIDDK PI/AN Intern Program indicates that all information provided is accurate and true to the best of my knowledge.  Also, I understand that submission of false or misleading information through this application process is grounds for immediate dismissal from the PI/AN Intern summer research program and/or experience and may result in the forfeiture of any associated benefits and financial support.
I agree:
Date: 2/4/2012