Research Trainee Application

Personal Information

* First Name

Middle Name

* Last Name

* Date of Birth

Gender

Current Address:

* Street

* City

State

* Zip Code

Telephone Number(s) with area code:

Day

Evening

* Cell

* E-mail address:

Department Information

Type of Research Training (Choose One)

* Department Supervisor Full Name

* Department Supervisor E-mail

* Department Name

Department Contact Name

Department Contact E-mail

Additional Information

Are you a current University of Miami (UM) student?

Are you a current Miller School of Medicine (MSOM) Medical Student?

Are you a current Univeristy of Miami (UM)/Miller School of Medicine (MSOM) Graduate or PhD Student?

Have you ever been a trained or volunteered at UM/MSOM?

If yes, please indicate:

* UHealth Department

Location

* Trainee Position

Start Date

End Date

Contact / Supervisor

Name(s) and Department(s) of family members employed at the University of Miami (if applicable):

* Graduation Year

Citizenship Status:

Do you have an F1 Visa?

Emergency Contacts

* Name:

* Relationship to you:

* Cellular Number:

Telephone Number:

Physician's Name:

Hospital Affiliation:

Physician's Telephone Number:

Education, Training, and Interest

* Relevant Education - If student, indicate: Academic Affiliation

* Relevant training, skills, and experience:

* Why do you choose to be a research trainee at the University of Miami?

Signature

I certify that all statements in this application are true. I also agree that if I am accepted as a research trainee, I will abide by all regulations of the University of Miami.

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Applicant's Signature