STEP UP

National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases Office of Minority Health Research Coordination
Short-Term Education Program for Underrepresented Minorities (Undergraduates) To learn more about NIDDK you may visit our website a http://www.niddk.nih.gov
*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:
*(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: (i.e. STEP-UP, MARC, SIP)	Yes No
NHSSSRP : most recent year
STEP-UP: most recent year
How did you learn about this program?	Friend Advisor/Mentor Promotional Flyer Website (please provide URL/Name below) Other (please specify below )
Other NIH Program (explain):
Other NIH Program: most recent year
Relative at NIH:	Yes No
If yes, relative's employer:
STEP-UP Coordinating Institutions. There are four National STEP-UP coordinating centers where students may choose to do their research. These institutions may offer specialized research programs, and limited housing may be available at the student�s expense. If you are interested in being considered for one of these STEP-UP programs, please indicate your first, second, and third choice below. Information on these programs may be found on the STEP-UP website.
First Choice:
Second Choice:
Third Choice:
Other Institution:
* All students selected for the STEP-UP program are required to have their own health insurance. Will you have health insurance at the time you participate in the program?	Yes No

Future Contact Information Please provide contact information for someone who will know of your whereabouts four years from now. The STEP-UP Program would like to know what impact STEP-UP had on your educational and career choices in addition to keeping you abreast of research education and career development opportunities.
First Name:
Last: Name:
Street Address 1:
Street Address 2:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email Address:

Demographic Information
*Date of Birth:
Gender:
*Hispanic:	Yes No
*If yes above, your Nationality:
If Other Nationality, please specify:
*Race:
If Other Race, please specify:

Family Income Family income: Individuals who are applying to the STEP-UP 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:

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:
*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.


References (Two Letters of Recommendation are required from individuals who are familiar with your academic abilities and accomplishments. IF YOU WERE A STEP-UP OR NHSSSRP PARTICIPANT IN A PREVIOUS SUMMER PROGRAM, one of the two letters MUST be from your most recent STEP-UP research mentor.) Please have the individual writing your recommendation submit a signed letter directly to the email address or mailing address 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:
*(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:
*(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 STEP-UP 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, 2010. 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. 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 from the website. Letters of Recommendation may be mailed or submitted electronically to: STEP-UP Undergraduate Program The Scientific Consulting Group, Inc. 656 Quince Orchard Road, Suite 210 Gaithersburg, MD 20878-4990 Email: stepup@scgcorp.com
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 STEP-UP 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 STEP-UP summer research program and/or experience and may result in the forfeiture of any associated benefits and financial support.
I agree:
Date:	2/9/2010

Short-Term Education Program for Underrepresented Minorities (Undergraduates)

NOTICE TO ALL APPLICANTS