How to Apply to EyeSTAR Program

Name:

Address:

Phone:                                                                         Pager:

E-mail Address (if applicable):

Social Security Number:

Residency Status:        □  I am a U.S. Citizen             □ I am a citizen of:

                                                                                           □ My U.S. Visa Status is:

EyeSTAR Program:      □  Residency-PhD                  □ Residency-Post Doctoral Fellowship

College:

Medical School:

Internship:

Residency:

Research Experience:

Desired Ph.D. discipline (if chosen):

PhD (if completed): 

Post-doctoral fellowship discipline:

Please submit the following

• PERSONAL STATEMENT: Summarize the research you have done, including your background, interests, special accomplishments, significant findings and the research area you wish to pursue in the STAR program.  Discuss the role you expect research to have in your long-term career. Indicate any Ph.D. departments you wish to consider.
• TRANSCRIPTS: Medical, Graduate, Undergraduate (if available).  Copies of official transcripts are acceptable.
• SCORES: ECFMG, GRE, MCAT, NBME, other scores (as applicable).  Copies of official scores are acceptable.
• CURRICULUM VITAE and REPRINTS OF PUBLICATIONS, if any.
• THREE LETTERS OF RECOMMENDATION: Please use the enclosed forms.  Forms and letters are to be mailed by your evaluators.  One of these letters should be from the faculty member with whom you have most recently done extensive research.  He/She should address your potential for future research contributions.
   

• I certify that the information in this application is true and correct to the best of my knowledge.

  Signature:                                                                                                         Date: