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AGA Investing in the Future (IITF) Student Research Fellowship Application
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Applicant Name (First, Middle I., Last):
Instructions: Please use 11 point font and complete all sections of the application.
___________________________________________________________________________________________
Last Name:
First Name:
Middle Initial:
State:
Zip:
Current Address:
City:
Non-Institution Email (Yahoo, AOL, etc.):
Phone:
□ Male
Gender:
□ Female
__ Black/African American __ Hispanic/Latino American __ American Indian
_____ Alaska Native __ Pacific Islander
Ethnicity:
□
Freshman
□
Sophomore
□
Junior
□
Senior
□
1st Year
□
2nd Year
□
3rd Year
□
4th Year
Undergraduate*:
Medical School:
Current Institution:______________________________________________________________________
Address:______________________________________________________________________________
City, State, Postal Code: _________________________________________________________________
Current Coursework and Grades: Please explain any unsatisfactory grades.
Course
Grade
Explanation for Unsatisfactory Grade(s)
*If you are an undergraduate student, you are required to provide a transcript. An unofficial copy is
acceptable.
What high school did you attend (Provide the school name, city and state)?
___________________________________________________________________________________
What was your GPA? __________
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AGA Investing in the Future (IITF) Student Research Fellowship Application
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Applicant Name (First, Middle I., Last):
What is/was your GPA as an undergraduate?________
If applicable, what is your GPA as a medical/graduate student? ________
___________________________________________________________________________________________
List Your Previous Research Experience. Mark “NA” if not applicable.
Institution/Location
Type of Research
Date of Research
Research Supervisor
Why have you selected gastroenterology and or nutrition research for your summer project (select all that apply)?
I have never conducted this type of research.
_____Yes
_____ No
I was encouraged by a peer.
_____ Yes
_____ No
I was encouraged by staff/faculty at my institution.
_____ Yes
_____ No
I was encouraged by the opportunity provided by this award.
_____ Yes
_____ No
I have a family member who is affected by digestive diseases.
_____ Yes
_____ No
Other (Type your answer here)
What is your research interest? (Check all that apply)
□ Clinical Practice
□ Epidemiology
□ Esophageal
□ Gastric and Duodenal Disorders
□ Gastroenterological Oncology
□ Growth, Development and Child Health
□ Hormones, Transmitters, Growth Factors and their Receptors
□ Imaging and Advance Technology
□ Immunology, Microbiology and Motility
□ Intestinal Disorders
□ Liver and Biliary
□ Neurogastroenterology and Motility
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AGA Investing in the Future (IITF) Student Research Fellowship Application
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Applicant Name (First, Middle I., Last):
□ Nutrition and Obesity
□ Outcomes
□ Pancreatic Disorders
Mentor Preferences: For the summer research project, from the Investing in the Future Mentor Roster, select, in
order of preference, three faculty members with whom you would like to work.
Faculty Member
Institution
Area of Study
1.
2.
3.
If you are selected to work with your “first choice” mentor, will this represent a new research area?
_____ Yes
_____ No
Letters of Reference: Provide two letters of reference from a past/current teacher, research instructor/mentor or
supervisor. Provide an email address for each reference. Limit each letter to one (1) page.
Please list below the name, title, and address of the individual who will be submitting the letter of recommendation.
Reference Name
Title/Relationship to Applicant
Reference Email Address
Reference Name
Title/Relationship to Applicant
Reference Email Address
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AGA Investing in the Future (IITF) Student Research Fellowship Application
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Applicant Name (First, Middle I., Last):
Personal Statement: In 300 words or less, please explain your motivation for pursing this fellowship and your
eligibility for this award. Consider the following when preparing the statement: What are your short and long term
educational and or career goals? How have you begun to lay the foundation for these goals? How does this
fellowship fit into these goals? Do you come from an educational, cultural or geographic background that is
underrepresented in this area of study? Have you demonstrated a commitment to diversity in the academic,
professional or civic realm through your work/school experience? Are you a first-generation US citizen or the first
generation in your families to graduate from a four-year college and or attend medical school? If selected, how will
this experience enhance your education/career future.
I certify that the information contained in this application is correct. I also understand that falsified information will
disqualify me as a candidate for this award.
Applicant Signature:__________________________________________________Date ____________________