|
Fields marked with an * must
be completed to send the form electronically. |
*First name
|
*Last name
|
M.I.
|
*Address
|
*City
|
|
*State/Country
|
*Zip Code/Mail Code
|
|
*Day Phone (w/area code)
|
Evening Phone (w/area code)
|
|
*E-mail address
|
Citizenship
|
|
| The University of Kansas has an
affirmative action program and is an equal opportunity Institution.
In order to comply with federal government regulations under Title
VI of the Civil Rights Act, Title IX of the Education Amendments,
the University seeks voluntary disclosure of information from applicants
for reporting purposes only. Disclosure of date of birth is voluntary,
and this information will be used for identification purposes when
there is duplication of students’ names. A decision not to
provide this information will not affect decisions on admission,
assistantships, or awards. If you so choose, please provide the
following information, as appropriate. |
Date of Birth (month, day, year)
|
Gender:
Male
Female |
|
| Ethnic origin:
|
|
| TESTING: Please provide us
with your Graduate Record Examination (GRE) scores (the subject
test is not required). International applicants will take the Test
of English as a Foreign Language (TOEFL). The TOEFL score cannot be more than 2 years old. |
| GRE |
|
|
Verbal
|
Verbal Percentile
|
|
Quantitative
|
Quantitative Percentile
|
|
Analytical
|
Analytical Percentile
|
|
Date GRE was taken:
|
(If the GRE has not yet been taken, please indicate
the date it will be taken). |
|
TOEFL (foreign applicants only)
|
Date TOEFL was taken:
|
|
TSE (foreign applicants only)
|
Date TSE was taken:
|
|
| EDUCATION: Please provide
a chronology of your university-level education: |
|
Institution
|
Major
|
|
Degree
|
Date of completion (00/00/00)
|
|
Overall GPA
|
Science GPA
|
|
Institution
|
Major
|
|
Degree
|
Date of completion (00/00/00)
|
|
Overall GPA
|
Science GPA
|
|
| REFERENCES: Please list the
names, addresses and phone numbers of the three (3) persons
who will be sending reference letters. |
Reference 1 (First and last
name)
|
Phone number (w/area code)
|
E-mail
|
Address (City, State, Zip Code, Country)
|
Reference 2 (First and last
name)
|
Phone number (w/area code)
|
E-mail
|
Address (City, State, Zip Code, Country)
|
Reference 3 (First and last
name)
|
Phone number (w/area code)
|
E-mail
|
Address (City, State, Zip Code, Country)
|
PERSONAL STATEMENT: Please
input a one page statement of why you wish to pursue graduate study
at The University of Kansas Medical Center. Career goals may also
be included.
|
RESEARCH AND WORK EXPERIENCE:
Concluding with your present position, list your employement history
and experience. Include all research and laboratory experience,
even if you did not hold a paid position.
|
HONORS:Please list any honors
or awards you have received.
|
PUBLICATIONS: List, in chronological
order, the titles, authors, and complete references to all publications
or abstracts on which your name appears.
|
STUDENT PREFERENCES FOR AREAS
OF RESEARCH EMPHASIS
By the end of the first year of studies, students select a thesis
and research advisor from one of the 14 areas of research emphasis.
Depending on the faculty member chosen, the student will receive
their degree in one of the 7 degree granting departments/programs
now existing at KUMC. Please indicate below your top three preferences
regarding a potential area of research emphasis (students are free
to change their area of research anytime during the first year). |
| First Choice |
|
| Second Choice |
|
| Third Choice |
|
|
|
|
©
The University of Kansas Medical Center