Scripps Research Logo

Internship Application

Summer Immunology and Virology Undergraduate Fellowship - 2012

PERSONAL INFORMATION
Name (Last, First, M.I.):
Gender: Male Female Not Disclosed
Permanent Address:
Daytime telephone:
Evening telephone:
E-mail address:
Current Address:
Daytime telephone:
Evening telephone:
 
ACADEMIC HISTORY
Name & location of college/university currently attending:
Name & location of college/university previously attended:
Major:
Grade Point Average:
Date (or expected date) of conferral of degree:
List 2 faculty members from whom you have requested a letter of recommendation. The letters should come from faculty who know your academic/research work. Please include a complete mailing address and telephone.
Honors and awards:
 
GENERAL INFORMATION
Have you participated in a research program, or had any research experience? Yes No
If yes, name of institution:
Name of investigator with whom you worked:
Area of work experience:
Year:
Length of research experience:
Other related work experience:
Dates you are available for the summer undergraduate fellowship (From-To):
 
Do you need housing? Yes No
 

STATEMENT OF GOALS

Please include below a Statement Of Goals, or mail a typed, double-spaced document, stating your research interests, experience, education goals, career objectives and any information which may aid the selection process.

My future goals include the pursuit of:
Ph.D. :
M.D. :
M.D./Ph.D. :
R.N. :
Other:


Immunology and Virology Areas of Interest:

To help us place you in an appropriate laboratory, please indicate topics that are of major interest to you with a "1". Use "2" to indicate secondary interest. Please indicate several areas of interest. Although we will try and match your interests, all labs may not be able to accommodate a student fellow.

T cells cell-cell interactions
B cells homeostasis
cancer development
infectious diseases gene regulation
HIV disease recombination
inflammatory bowel disease structure
autoimmunity signal transduction
inflammation innate immunity

List several TSRI Immunology and Microbial Sciences Labs whose research sounds interesting to you.

Confidential Applicant Voluntary Survey

To the Applicant: The Scripps Research Institute (TSRI) is a government contractor subject to certain equal employment opportunity laws. Under Executive Order 11246, as amended, the Federal government requires government contractors to collect equal employment opportunity data from job applicants. The information requested below is used only for purposes of compliance with these federal equal employment opportunity requirements.. The information provided will be kept confidential, except as required by law.

Your submission of this information is completely voluntary, is greatly appreciated.

In addition, TSRI is an Equal Opportunity Employer, and as such, conducts all employment related activities without regard to unlawful considerations of race, national origin, gender, disability, age, religion or any other protected category.


Ethnicity

Hispanic or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino.
Not disclosed.

Race

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.
White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American - A person having origins in any of the black racial groups of Africa.
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Two or More Races - All persons who identify with more than one of the above five races.
Not Disclosed.