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1. Personal Information

 
 14% of survey complete.
Application Deadline: Friday, February 10th, 2017
Click here to access the essay questions.

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* 1. First Name

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* 2. MI

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* 3. Last Name

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* 4. UCSC student #

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* 5. UCSC College Affiliation

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* 6. Last 4 digits of SS# (If not applicable, please enter "none")

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* 7. Permanent (Home) Address:

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* 8. Current Address

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* 9. Email

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* 10. What is your ethnicity? For more information please see: http://grants.nih.gov/grants/funding/women_min/race_ethnicity_qa.htm

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* 11. What is your race? Check all that apply. 

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* 12. Do you have a disability? This information is used only for aggregate statistical reporting and to provide reasonable accommodations, as requested. 

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* 13. Are you disadvantaged? For more information please see: http://www.ninds.nih.gov/diversity_programs/definitions.htm

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* 14. Language(s) Spoken at Home:

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* 15. Gender:

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* 16. Date of Birth

Date

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* 17. City and State or Country of Birth:

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* 18. Are you a US Citizen?:

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* 19. If you are NOT a US Citizen, are you a Permanent Resident?
*Federally funded programs  we cannot financially support students who do not either have US citizenship or a permanent resident card. If you have an F1 or other Visa or you are not living legally in the US and you would still like support we have private and state funds you can be eligible for. 

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