Date:

SS#:

Present Address: Enter Street, City, State, Zip.

Present Phone:

Permanent Address: Enter Street, City, State, Zip.

Permanent Phone:

Email Address:

Date Appointment Desired:

EDUCATION [list all schools attended]:

Undergraduate Education:
For each one list: Dates Attended, Institution/Location, Major, Degree & Date

Graduate Education and/or Medical School:
For each one list: Dates Attended, Institution/Location, Major, Degree & Date

AWARDS AND HONORS (highlights):

RESEARCH EXPERIENCE/PUBLICATIONS:

REFERENCES:
List the names & addresses of two (2) persons from whom we will recieve recommendations on your behalf:
1.

2.


DOCUMENTATION REQUIRED:
1. Complete and submited online application, together with a
    PERSONAL STATEMENT of your plans for postgraduate training
    and future career plans, and a CURRENT CURRICULUM VITAE
    emailed to:

    lpradhan@bidmc.harvard.edu

    or sent to:

    Leena Pradhan, PhD
    William J. von Liebig Summer Research Fellowship
    4 Blackfan Circle,
    HIM Room 130
    Boston, MA 02115

2. Completed applications must include:
    a) Dean/Advisor or Program Director's Letter
    b) Two additional letters of recommendation

These documents should be sent to the Program directly, at the address listed above.

Application DEADLINE for summer 2008: January 10, 2008

Harvard Medical School and participating institutions prohibit discrimination on the basis of race, color, national origin, marital status, religion, gender, age, physical or mental handicap, and status as a disabled veteran or veteran of the Vietnam era. This policy extends to all rights, privileges, programs and activities.

You will receive a copy of your submission by email.