"Be worthy to Serve the Suffering" Alpha Omega Alpha Honor Medical Society Key Background

Carolyn L. Kuckein Student Research Fellowship

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* Indicates required fields

Student Information
* Salutation
* First Name
Middle Initial
* Last Name
* Street 1
Street 2
* City
* State
* Zip
* Cell Phone
* E-mail
* Year of graduation
* Title of proposal

Councilor Information
* School
* Councilor
Councilor Email *
Councilor Phone
* Councilor Street 1
Councilor Street 2
* Councilor City
* Councilor State
* Councilor Zip

Mentor Information
Mentor First Name
Mentor Last Name
Mentor Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
Mentor Email
Mentor Street 1
Mentor Street 2
Mentor City
Mentor State
Mentor Zip

Mentor2 Information
Mentor2 First Name
Mentor2 Last Name
Mentor2 Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
Mentor2 Email
Mentor2 Street 1
Mentor2 Street 2
Mentor2 City
Mentor2 State
Mentor2 Zip

Dean Information
Dean First Name
Dean Last Name
Dean Member ID (If s/he is member, please enter the member id. See “Locate a Member” at left sidebar.)
Dean Email
Dean Street 1
Dean Street 2
Dean City
Dean State
Dean Zip

* IRB or IACUC required?
Submission Research
Note: Files must be submitted in one PDF in the following order:
1.Checklist
2.Summary
3.Bibliography
4.IRB or IACUC approval or proof of application
5.Student CV
6.Mentor letter
7.Mentor CV
8.Councilor endorsement letter
9.Dean’s endorsement letter