Demographic
Last Name *
First Name *
Middle Name
Street Address Line 1
 Street Address Line 2
City
 State
 Postal Code
 Country

Legal Residence/Citizenship (if different from above)
City
 State
 Country
 Citizenship Country
Additional Demographic (Optional)
Date of Birth Gender (M/F) Race/Ethnicity (optional, choose one)
Contact Information
Home Phone Cell Phone Email *
Academic Background
Academic Level School Name Location
(City/State)		 Start Date
 End Date
Degree Type (BS, BA) Field
 Degree Date
Academic
Level		 School
Name		 Location
(City/State)		 Start Date End Date
Degree Type (BS, BA) Field
 Degree Date
Academic
Level 		School
Name 		Location
(City/State) 		Start Date End Date
Degree Type (BS, BA) Field
 Degree Date
Academic
Level		 School
Name		 Location
(City/State)		 Start Date End Date
Degree Type (BS, BA) Field
 Degree Date
Academic
Level 		School
Name 		Location
(City/State) 		Start Date End Date
Degree Type (BS, BA) Field
 Degree Date
Academic
Level 		School
Name 		Location
(City/State) 		Start Date End Date
Degree Type (BS, BA) Field
 Degree Date
Grade Point Average Please report your overall cumulative and science course grade point averages for your undergraduate education and graduate education (if applicable) below.

Undergrad
Cumulative GPA 		Undergrad
Science GPA 		Graduate
Cumulative GPA 		Graduate
Science GPA
Graduate Record Exam Please report your most recent Graduate Record Exam (GRE) results (general test only). If you have not yet taken the exam, please list the date you anticipate taking the exam.

Date Verbal Score Quantitative Score Analytical Score
Test of English as a Foreign Language (TOEFL) A TOEFL is required of any international applicant who is from a country where English is not the primary language and who has not attended a university or college in the US, full-time, for at least two consecutive years. Please report your PBT, CBT or IBT TOEFL scores below; if you have not yet taken the exam, please list the date you anticipate taking the exam.

Date Total Score Listening or
IBT Reading 		Structure/Writing
or IBT Listening 		Reading or
IBT Speaking 		TWE, CBT Essay
or IBT Writing
Research Interests Please use the fields below to indicate your preferred areas of research.
Primary Secondary
Tertiary Other
Birkbeck Program
Are you interested in the Birkbeck Program?
Yes No
If yes, please complete the Birkbeck Essay. If no, please skip to the Standard Essays section.

Where did you hear about the Birkbeck Program?
A.C.S. RFUMS Website Flier Other


Birkbeck Essay - Describe the qualities you feel make you a good candidate for the Birkbeck program.
Explain the role of Structural Biology/Bioinformatics in your career goals.

Standard Essays Please detail your experiences in the relevant areas below.

Professional Organizations/Certifications/Honors



Research and Work Experience



Publications



Personal Statement



Comments/Questions

By clicking the submit button, you are agreeing that all information listed above is complete and true to the best of your knowledge. Once this form is submitted, you will be redirected to the checklist for completion of the application process.