Vanderbilt University Department of Anesthesiology
Summer Internship Program Application 2013
Complete applications are due by February 15, 2013.
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Section I: General Information
Name (last, first): Click here to enter text.
Student Classification (Indicate year of study in space provided, i.e., freshman, 3rd year, etc.)
☐ High School Student Click here to enter text.
☐ Undergraduate Student Click here to enter text.
☐ Graduate Student- Masters, PhD Click here to enter text.
☐ Medical Student Click here to enter text.
Name, location of institution currently attending: Click here to enter text.
Major: Click here to enter text.
GPA: Click here to enter text.
Anticipated Graduation Date: Click here to enter text.
Graduation date (Post-baccalaureate students only): Click here to enter text.
My highest educational goal:
☐ Bachelor’s Degree
☐ Master’s Degree
☐ Doctorate/Professional Degree (e.g., MD, PhD, DrPH)
My career goal: Click here to enter text.
I learned about the Vanderbilt University Summer Anesthesiology Program from:
☐ Website
☐ Career Center
☐ Classmate/Friend
☐ College Professor/Advisor
Date of Birth (month/date/year): Click here to enter text.
Gender: Female: ☐ Male: ☐
Vanderbilt University Department of Anesthesiology
Summer Internship Program Application 2013
Local Address:
Street Address: Click here to enter text.
City:Click here to enter text.
State: Click here to enter text. Zip Code: Click here to enter text.
Permanent Address:
Street Address: Click here to enter text.
City:Click here to enter text.
State: Click here to enter text. Zip Code: Click here to enter text.
Local Phone: Click here to enter text. Cell Ph: Click here to enter text. Home Ph: Click here to enter text.
Email: Click here to enter text.
Section II: Short Answers
Please respond to each question in 250 words or less.
1. Describe your past community service, leadership, and/or research experiences.
Click here to enter text.
2. How does participation in the Vanderbilt University Summer Research Program with the
Department of Anesthesiology fit with your short-term and long-term academic goals? Be
specific.
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3. List any programming skills and/or experience with statistical software packages (SAS, SPSS,
STATA, Matlab, etc.)
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Vanderbilt University Department of Anesthesiology
Summer Internship Program Application 2013
Section III: Application Checklist
☐ Completed Section I and II
☐ Resume or Curriculum Vitae
☐ Official University/School Transcript
☐ One letter of reference from a professor or advisor at your university or school. Mailed letters must
be sealed and have recommenders’ signature across the back of the sealed envelope.
Acknowledgement
By my signature, I acknowledge that the information contained in this application is true and accurate to
the best of my knowledge and agree to being contacted in the future.
Signature (type if submitting electronically, sign if submitting paper copy:
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Date: Click here to enter text.
Complete applications are due by February 15, 2013. Applications may be
submitted by email, fax or mail, but must be received by the deadline.
Mailing Address:
Perioperative Data Systems Research
1301 Medical Center Drive
4648 The Vanderbilt Clinic (TVC)
Nashville, TN 37232-5614
Attn: Sandra Holtzclaw
Email Address: sandra.holtzclaw@vanderbilt.edu
Fax number: 615-936-6493