UNDERGRADUATE STUDENT APPLICATION

Applicants are strongly encouraged to read the FAQ on the SMART-MIND program website before applying.

The first week of orientation and pre-program training is mandatory.

Form Login Account (highly recommended)

You must complete this form in its entirety in order to submit. Creating an account will enable you to partially complete this form and return later to finish it. The login account you create is only for this form.

New Users / Returning Users CLICK HERE to setup or return to your account for this form.

BIOGRAPHICAL INFORMATION

Student First Name *

Student Middle Name *

Student Last Name *

Gender *

Student Date of Birth (mm/dd/yyyy) *

Student ID Number (if UTEP student):

Note: The email address you enter below will be used by the program as the principal means of communication with you. This address will not be shared with other programs without your consent.

Upon submission, a copy of your application will be sent to the email address you enter.

Personal Student Email Address *

Re-enter Email Address *

Student Cell Phone Number (XXX-XXX-XXXX)) *

Student Home Phone Number (XXX-XXX-XXXX) *

I am a (select one) *

U.S. citizen

U.S. legal resident (green card holder)

Note: This program can only support US Citizens of Permanent Residents

Answering the questions below about race and ethnicity is optional. Information collected, however, will be used for important statistics. Your cooperation is highly appreciated.

Race (select all that apply)

Ethniticy (select one)

Hispanic or Latino

Not Hispanic or Latino

Do you belong to any of the following groups that are underrepresented in science? *

Individuals with physical or mental disabilities. As described in the Americans with Disabilities Act of 1990 (ADA)

Individuals from a low-income family. Defined as a family with annual income below thresholds published here

Individuals from a rural or inner-city educational environment

I do not belong to any of the above categories

I do not wish to provide an answer

HEALTH INSURANCE INFORMATION

To be accepted into the program, applicants must provide proof of health insurance. Please complete the information below.

If for any reason you cannot provide the information at this time, please mark the appropriate box below, and send us the information requested here, plus copies of your health insurance card (front and back), by email at a later date.

Name of Provider (Health Insurance Company)

Plan Name

Subscriber Name

🛈

Benefits ID

Group Number (if applicable)

Network Number (if applicable)

Please attach a pdf copy of your health insurance card (front and back)

Select one

*

I am unable to provide health insurance information at this time. For my application to be considered, I agree to provide such information by email to smartmind@utep.edu

I have provided all the required health information information above, including an uploaded copy of my insurance card (front and back)

PERMANENT ADDRESS

Address (Number and Street)

Address Line 2

Address Line 3

City

State

Zip Code

PARENT/GUARDIAN OR EMERGENCY CONTACT INFORMATION 1

Parent First Name *

Parent Middle Name

Parent Last Name *

Relationship (mother, father, spouse, etc.) *

Parent Cell Phone Number (XXX-XXX-XXXX) *

Home Phone Number (XXX-XXX-XXXX) *

Parent Email address (if applicable)

re-enter email address

PARENT/GUARDIAN OR EMERGENCY CONTACT INFORMATION 2

Parent First Name *

Parent Middle Name

Parent Last Name *

Relationship (mother, father, spouse, etc.) *

Parent Cell Phone Number (XXX-XXX-XXXX)) *

Home Phone Number (XXX-XXX-XXXX)) *

Parent Email address (if applicable)

re-enter email address

ACADEMIC INFORMATION

College/University Attending *

City *

State *

Major *

If other, please specify

GPA as of last Fall semester *

Minor (if none type NA) *

I am a (select one) *

Number of credit-hours completed so far *

Number of credit-hours currently enrolled in *

Expected date of graduation (mm/yy) *

Attach a PDF copy of your UNOFFICIAL transcript here to expedite the review of your application.

Do you have any prior research experience? (other than laboratory course work) *

If yes, briefly describe your research experience in the space below (250 words or less).

Be sure to include the following:
1. Name of the school and department where the research took place
2. Name of the advisor/mentor who supervised (or is supervising) your research
3. Title of the project you were (or are) involved in
4. Length of time you were (or have been) involved in the project
5. A brief description of the project.

Research Experience

0/250 words

Which of the following best describes your plans after graduation with a bachelors degree? (Select one) *

Graduate School Bound

Professional School Bound (Dental, Medical, Pharmacy, etc.)

Teaching Bound (Elementary, Middle, High School)

Workforce bound (other than teaching)

PROJECT SELECTION

In the spaces below, enter the names of three professors listed on the SMART-MIND website whose projects interest you. List them in order of preference from 1 (most preferred) to 3 (least preferred). If selected to participate, you will be assigned to work on the project directed by one of these three professors

Choice 1

*

Choice 2

*

Choice 3

*

Choice 4

*

Choice 5

*

REFERENCES

Please arrange for two professors to complete recommendation forms for you. The recommendation form link will be sent to your recommenders via e-mail and the deadline for submission is February 2, 2024.

Enter below the names and contact information of those two professors.

Reference 1

Title *

r1.First Name *

Middle Name or Middle Initial

Last Name *

Institution *

Department

Phone Number (XXX-XXX-XXXX) *

Extension (if any)

Email Address *

Re-enter Email Address *

Reference 2

Title *

r2 First Name *

Middle Name or Middle Initial

Last Name *

Institution *

Department

Phone Number (XXX-XXX-XXXX) *

Extension (if any)

Email Address *

Re-enter Email Address *

STUDENT PERSONAL STATEMENT

The student statement must fit in the space provided = 500 words. You may copy and paste from your favorite word-processing software. To have a competitive application, you must include the following in your narrative:

a) Motivation/rationale for your desire to participate in the projects that you selected.
b) Prior academic courses and/or professional experience that prepared you for those projects.
c) The expected impact of this research experience on your future academic and career plans.

Personal Statement *

0/500 words

ACCOMMODATIONS

I am a visiting student from another institution and I: *

will need dormitory accommodations

will not need dormitory accommodations

I am a local/UTEP/NMSU student

How did you hear about us? *

If selected other, please mention how

IMPORTANT NOTE

You are almost done.
PLEASE, CAREFULLY REVIEW YOUR ANSWERS BEFORE SUBMITTING AND TAKE NOTE OF YOUR LOGIN INFORMATION.

If you have questions about this application, contact us at couri-programs@utep.edu

I certify that the information above is correct to the best of my knowledge *

yes