Minority Health and Health Disparities International Research Training (MHIRT)
Sponsored by the National Institutes of Health
Minority Science Programs (MSP) School of Biological Sciences
Program Director Dr. Luis Mota-Bravo
University of California, Irvine
2016 STUDENT APPLICATION
Applications will be reviewed starting on Monday February 8, 2016. Please use a computer to fill in
the gray areas of this application, print the completed application and sign it.
Legal Name
Family/Last Name (Surname)
First Name
Male
Female
Middle Name
-
-
U.S. Social Security #
UCID number (if applicable):
Different names that may appear on your academic records:
Mailing Address (Use until:
No. and Street
City and State
ZIP or Country
Cell phone
E-mail:
)
Birthplace:
Permanent Address
No. and Street
City and State
Zip or Country
E-mail:
Permanent Telephone:
Birthdate:
City, State or Country
Month/Day/Year
Ethnicity:
If Native American, your tribal affiliation:
Country of Citizenship:
If you are not US Citizen, are you a US Permanent Resident?
No
Yes
Current Class Status:
Freshman:
Sophomore:
Specify major/area:
Degree Objective:
Junior:
Senior:
Graduate:
Date your Fall 2016 classes begin:
Master’s Degree
Ph.D. Degree
M.S./Ph.D.
Medical:
Other:
(this field must be completed)
M.D./Ph.D.
Other:
Specific area of interest:
List in chronological order all colleges and universities attended since high school. Please include institutions you
are currently attending and any previous work completed in preparation for the MHIRT program. One copy of
official transcripts are required for each institution listed.
College/University
and Location
Dates Enrolled
Mo/Yr -Mo/Yr
Units
Completed
Degree and
Date conferred
Cum.
GPA
Major Field
of Study
Indicate your undergraduate science G.P.A:
Describe academic work in progress and anticipated courses of study prior to participation in MHIRT.
What factor(s) made you interested in the Biological/Biomedical Sciences?
Describe previous research training and other experiences which are relevant to MHIRT.
What are your plans to continue your research training after your participation in the MHIRT Program (for example,
plans for the enrollment in graduate school)?
Indicate your order of preference for a particular MHIRT research training area and foreign site according to the
program announcement.
1.
2.
3.
Describe the level of competence in speaking, understanding, reading and writing, languages other than English, and
state how this ability was acquired.
With your application, please include:

Copy of transcripts

The transcripts of UCI students should show that they have passed Bio Sci 194S (Safety and Ethics in
Research) or students should enroll in Bio Sci 194S during Spring 2016. Students are required to enroll in
Spring 2016 Bio 197 MSP Research Seminar. Students that are not participating in UCI MSP programs
(MBRS, MARC and URM) and have done research should submit a letter of recommendation from their
research advisors describing their research experience.

Two page personal statement (see form below)
Note: The MSP Selection Committee will not review incomplete applications. If you are pre-selected, you will
be contacted to set an appointment for an interview.
I hereby apply for admission to the Minority Health and Health Disparities International Research Training
(MHIRT) at the University of California, Irvine, and certify that to the best of my knowledge all of the above
statements are true and complete. I understand that submitted records and letter of recommendation will not be
returned, copied, or forwarded. I authorize the UCI Minority Science Programs personnel to access my student
records and monitor my academic progress. I agree to abide by the university policies and stated in the UCI General
Catalogue. After my participation in MHIRT, I agree to maintain contact with the UCI Minority Science Programs
personnel to track my career development to evaluate the outcomes of MHIRT.
_______________________________________________________________ ___________________________
Signature
Date
Return this application and all supporting documents to: MHIRT, Attn: Dr. Marlene de la Cruz, University
of California, Irvine, 1134 Biological Sciences III, Irvine, CA 92697-2527
Telephone (949) 824-2589, Fax: (949) 824-6599, e-mail: marlene@uci.edu
Application for the Minority Health and Health Disparities International
Research Training (MHIRT) at the University of California, Irvine
Statement of Purpose
Legal Family Name (Last Name)
First Name
Middle Name
State your general reasons for applying to MHIRT and your specific career interest. Please include background,
research interests and experience, future educational goals, personal attributes and program expectations. If
applicable, include you experience in laboratory methods and level of expertise. Please use a computer to fill in the
gray areas of this form (you may copy/paste from other documents). Please do not exceed 2 pages.
_______________________________________________________________ _____________________________
Signature
Date
Applications will be reviewed starting on Monday February 8, 2016.
Return this application and all supporting documents to: MHIRT, Attn: Dr. Marlene de la Cruz, University
of California, Irvine, 1134 Biological Sciences III, CA 92697-2527
Telephone (949) 824-2589, Fax: (949) 824-6599, e-mail: marlene@uci.edu