NIDDK

Alaska Native Undergraduate Summer Internship Program - Undergraduate Application

All fields marked with a * are required for Final Submission.
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:
*Veteran: Yes   No
*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)
Previous NIH research experience: Yes   No
If YES, what Program:
Other NIH Program: most recent year
Relative at NIH: Yes   No
If yes, relative's employer:
   
Future Contact Information
Please provide contact information for someone who will know of your whereabouts four years from now.
First Name:
Last: Name:
Street Address 1:
Street Address 2:
City:
State:     if not listed, please enter here: 
Zip:
Home Phone:
*Cell Phone:
Email Address:
   
Demographic Information
*Date of Birth: Click Here to Pick a Date
Gender:
*Alaska Native: Yes   No
*Race:
If Other Race, please specify:
   
Family Income
Family income: Individuals who are applying to the ANUSIP Program based upon disadvantaged background* are required to complete the following section. This information IS NOT based upon your personal financial status. Additional information e.g. a copy of your FAFSA (Free Application for Federal Student Aid) maybe requested for further clarification. (http://www.fafsa.ed.gov/)
*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:
Have you received or qualified for any of the following (Check all that apply)
Loans for Disadvantaged Student Program:
Pell Grant:
Scholarships from the U.S. Department of Health and Human Services under the Scholarship for Individuals with exceptional Financial Need:
Other Needs-based scholarship
or financial aid:
*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.
   
Academic Information
(An official copy of your college transcript is required and should be sent from your school to the address below)
*College in which you are enrolled:   
Other Institution:
College Mailing address 2/15 till 5/31:
*Street 1:
Street 2:
*City:
*State:     if not listed, please enter here: 
*Zip Code:
*Current classification:
*Anticipated graduation date (month): *Year:
*Current Cumulative GPA:
*School Grading Scale:
(i.e. 4.0, 5.0, other)
*Academic Major:
*Coursework: Include coursework currently in progress:
*Resume: Please insert your resume or CV. Include education, relevant research experience, scientific publications, honors and awards.
   
Employment and Volunteer Experience

Employment and Volunteer Experience

 Brief description
   
Honors and Awards      
Brief description Month Year
   
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
   
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.
Reference 1  
*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:
   
Reference 2  
*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:
   
*Personal Statement: Please state your research interest and long-term career goals, if known, and reasons for applying to the NIH/NIDDK ANUSIP 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!

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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:

    ANUSIP Undergraduate Program
    Winnie Martinez
    Program Analyst
    Alaska Native Undergraduate Summer Internship Program
    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. Once 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 ANUSIP 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 ANUSIP summer research program and/or experience and may result in the forfeiture of any associated benefits and financial support.
I agree:
Date: 5/21/2013