CBSE Graduate Diversity Fellowship & RMI Program

Date: *

Please mark one: *

Graduate Student

Undergraduate Student

Contact Information

First name: *

Middle name:

Last name: *

UCSC college affiliation:

Cell phone number: *

Enter N/A if you do not have a cell phone.

Current home phone: *

Permanent phone number: *

E-mail address (UCSC): *

Alternate e-mail address:

Permanent address

Address: *

City: *

Zip Code: *

State: *

Current address

Same: *

	Yes	No
Same as permanent address?

If no, please complete information below

Address:

City:

State:

Zip Code:

Personal Information

UCSC student number: *

Date of Birth: *

Gender: *

	Male	Female
Gender

City and state or country of birth: *

If yes, provide number:

NOTE:The Research Mentoring Institute is funded by the National Human Genome Research Institute (NHGRI), an agency of the US government, and can only offer financial support to students who are either U.S. citizens or permanent residents. Students who not US citizens or permanent residents are not eligible for RMI scholarships or fellowships.

The RMI does have a range of non-financial types of support available to help all UCSC students attain their academic goals, including help with graduate school applications, career advising, writing assistance, and a referral service. Please contact the program director for more information.

Racial or Ethnic Background

If other, please describe:

reCaptcha

Please enter the two words you see in the image below into the box provided. This helps stop automated SPAM bots from filling out this form.

Program Application