University of Minnesota Chemistry Department

Please complete the following Web-based application by March 15 to be considered for a Heisig Summer Research Fellowship. You will also need to have two letters of recommendation submitted to 135 Smith Hall by that same date. We will download your transcript.

Application Form

First Name Last Name

ID #

Date of Birth

Place of Birth (City, State or Province, Country)

Citizenship

Preferred E-mail address

Preferred Mailing address:

address

City State Zip

Phone (area code first)

Expected date of graduation

Overall cummulative Grade Point Average

Overall Grade Point Average in all science and math classes completed

Number of science and math courses completed

Are you currently involved in research yes no

If yes, who is your research advsor

What is your primary research interest in chemistry

Upon graduation I am interested in (check all that apply)

° Attending medical school yes no

° Attending graduate school in Chemistry yes no

° Attending graduate school in Biochemistry yes no

° Attending graduate school in Chemical Engineering yes no

° Attending graduate school in Material Science yes no

° Attending graduate school in Pharmacy yes no

° Working in industry yes no

Please use the space below to write a brief statement describing your long term career goals and indicate how this summer research program would help facilitate these goals.

The University of Minnesota is committed to the policy that all persons shall have equal access to its programs, facilities, and employment without regard to race, religion, color, sex, national origin, handicap, age, veteran status, or sexual orientation. In adhering to this policy, the University abide by the requirements of Title IX of the Education Amendments of 1972, by Sections 503 and 504 of the Rehabilitation Act of 1973, by Executive Order, 11246, as amended: 38 U.S.C. 2012, the Vietnam Era Veterans Readjustment Assistance Act of 1972, as amended; and by other applicable statutes and regulations relating to equality of opportunity.

Inquiries regarding compliance may be directed to Patricia A. Mullen, Office of Equal Opportunity and Affirmative Action, 419 Morrill Hall, 100 Church Street S.E., University of Minnesota, Minneapolis, Minnesota, 55455, (612)624-9547, or to the Director of the Office of Federal Contract Compliance Programs, Department of Labor, Washington D.C., 20210.

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