Research Experience in Neuroscience for Undergraduates
From Rural and Tribal Colleges - Summer 2009

(1) Applicant Contact Information
Name of Applicant (last, first, middle)
Mailing Address
(Street, Apt #, City, State, Zip)
Permanent Address
(If different from above)
Telephone (Home)
Telephone (Work)
Email Address
Emergency Contact
(Name, Contact Information [including phone numbers], Relationship)
(2) Applicant Academic Information
List High School(s) and College(s) Attended
Name Location Dates Attended Degree
Current College
Current Academic Level
Expected Graduation Date (mm/yyyy)
Indicate Grade Point Average (GPA) and scores for the following (if available): GPA Overall GPA Science Only Science Hours Completed
GPA Last Semester Hours Completed Last Semester
SRA ACT SAT
When did you begin college?



Year

   
Anticipated Major Subject Area:
Academic Honors, if any:
(3) Demographic information required by the NSF
Gender (select one) :  
US Citizenship:  
Permanent Resident Alien:  
Applicants who are biracial or multiracial may check more than one designation as appropriate.





Will you be the first person in your family to graduate from college?  
   
Applicant age:  
Number of dependents:  
Dependent ages:  
     
If you have a disability and require an accommodation, please contact either Dr. Bull Bennett (bbennett@ndatc.org), Tribal College Science Coordinator; North Dakota Association of Tribal Colleges (701) 223-4100 or Dr. Van Doze (vdoze@medicine.nodak.edu), Department of Pharmacology, Physiology & Therapeutics, University of North Dakota School of Medicine & Health Sciences (701) 777-6222. See also http://www.und.edu/instruct/spyle
(4) Applicant Recommendations

List the name, address, phone number, and email address of two instructors familiar with your abilities. Ask them to send a letter of recommendation to Dr. Van A. Doze, at the address below.
1:
2:

Applicant review and award notifications will begin on Monday, March 9th and continue until all the positions are filled with qualified applicants. The program will begin Monday, June 1, 2009.

Please direct your questions to either Dr. T. M. Bull Bennett (bbennett@ndatc.org), Tribal College Science Coordinator, North Dakota Association of Tribal Colleges (701) 223-4100 or Dr. Van A. Doze (vdoze@medicine.nodak.edu), Department of Pharmacology, Physiology & Therapeutics, University of North Dakota (701) 777-6222.

Please send letters of recommendation and transcipts to:

Dr. Van A. Doze, NSF-REU
Pharmacology, Physiology & Therapeutics
University of North Dakota School of Medicine
501 N. Columbia Rd., Rm. 5700A
Grand Forks, ND 58203
Email: vdoze@medicine.nodak.edu

(5) Autobiographical Sketch

In your own words, please discuss your academic plans, noteworthy scholarly achievements, career interests and objectives, work experience, community involvement and personal interests. Please also discuss how you learned about this program and why you are interested in participating. Also indicate why you wish to pursue a career in the sciences, including teaching. Three page limit.