Apply to the SHURP Program - 2014 Application Form

Please fill out the following form and then press submit. All additional materials must be mailed to the SHURP office.


This program is funded in part by grants from NIH and NSF. Therefore, we are unable to accept international students.



Contact Information

Last Name: First Name:


Middle Name:

Mailing Address


City: State:



Address valid until (MM/YY):

Cell Phone:

Current Phone Number (if different from cell):

Email Address:

Confirm Email Address:

Permanent (Home) Mailing Address


City: State: Zip:

Phone number:



Undergraduate Institution





Current Year in School:

Expected Grad Date (MM/YY):



Biographical Information

Gender: Male  Female 

Birthdate (MM/DD/YYYY):


Are you a U.S. citizen? Yes  No 

If no, do you have permanent resident status? Yes  No 

I-551 card number:

Other citizenship (indicate country):

Are you a first-generation college student? Yes  No 

Are you currently part of a research program (e.g. MARC, MBRS-RISE, McNair, etc.) at your
institution? Yes  No 

If yes, please indicate the name of the program: 


Will you be part of a research program (e.g. MARC, MBRS-RISE, McNair, etc.) at your
institution in the future? Yes  No 

If yes, please indicate the name of the program: 


Possible start date: 


We would like to know which graduate degrees you are interested in pursuing. Please rank the following degrees 1-4 in order of your interest, 1 being most interested. If you are not interested in a particular degree please select "not interested." If there is another degree you are interested please let us know, and rank it as well.


PhD Rank: 

MD/PhD Rank: 

MD Rank: 


Other:   Rank: 

Are you (please check)

African-American     Mexican-American     Puerto Rican    Asian    Caucasian 

Other Hispanic  (specify country)

Native Pacific Islander  (specify island)

Native American  (specify tribal affiliation)

Other  (specify)



Letters of Recommendation

Letter 1 will be sent by (name):

Letter 2 will be sent by (name):



How did you hear about the program? (Please check all that apply)

 Leadership Alliance



 Graduate School Fair

 Biomedical Sciences Career Program

 NSF Website

 Home University (or another school) site. Name of school: 

 Other online directory: 

 Previous SHURP Participant. Name: 

 Faculty member at your institution




Personal Statement - please copy your personal statement below.



CV - please copy your CV below.


Application Information

Application for Summer 2016


Apply through the Leadership Alliance. For more information about the Leadership Alliance, including the application process click here.

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