U.S. Bose Scholars Program Application

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This will allow you to return at a later date to finalize your application.

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Note: To be eligible to participate in a study abroad program, you must be enrolled in an undergraduate or graduate degree program at the time of application and during the entire study abroad program.

Personal Info

First Name *

Middle Name *

Last Name *

Address *

City *

State *

Zip *

Email Address *

Telephone *

Cell phone

Academic Info

Current School or College *

Major(s) *

Cumulative Undergraduate GPA *

Projected graduation date *

Month

Day

Year

Scanned Copy of Transcript *

Recommendations

A letter of recommendation from a faculty member, advisor or lab supervisor.

Letter of Recommendation *

Letter of Recommendation #2

Letter of Recommendation #3

Passport Info

If you do not have a passport, apply for one now! Please include a scanned copy of your passport with your application.

Passport Number

Country

Date Passport Expires

Month

Day

Year

Date Passport Issued

Month

Day

Year

Scanned Copy

Please include a scanned copy of your passport with your application.

Additional Information

Have you ever been disciplined by any college/university for academic or non-academic conduct? *

If yes, please explain.

Have you ever been convicted of a felony or a criminal offense? *

If yes, please explain.

Technical Background *

Technical background—courses, lab work, techniques exposed to and past lab experience. Including a description of extracurricular activities, such as volunteer, employment, student organizations.

Statement of Purpose *

A statement of what you hope to gain from the experience, with attention to both scientific and cultural experiences. Project ideas of what you would like to work on and suggestions of Indian institutions that you might like to work at (A list of partner institutions in India is available on the Khorana website).

Agreement

I affirm that the information I have given on this application is correct to the best of my knowledge. I also affirm that I meet the following eligibility requirements of a Study Abroad Program 1. I am in good academic standing (not on probation) and meeting the quality of work standards for cumulative GPA as defined by my school or college. 2. I am enrolled in an undergraduate or graduate degree program at the time of application and also during the study abroad program I am applying for. 3. I agree to enroll and participate in any program requirements (e.g. course work, research, papers, etc.) prior to or following the internship experience. 4. I understand and agree, that at the time of my departure, if I fail to meet any of the requirements, as stated above, that I will be declared ineligible and will not be allowed to participate in the program. 5. I authorize the university to release an unofficial transcript, which includes grades from the most current semester completed before my study abroad departure date to Khorana Program administrators to confirm my continued academic eligibility. 6. I understand and accept responsibility that if I purchase my airline ticket and then am declared ineligible to participate in the study abroad program, I may lose the value of that ticket. 7. I understand that my application may be shared with partner institutions in India during the student selection process.

I agree *

I certify that I have read the foregoing entire document and have had the opportunity to ask questions about it. I hereby acknowledge that I understand it and agree to it.

Certify Name *

Type name to certify.

Certify Date *

Month

Day

Year

Waiver of Right for Pictures

I agree

Check here if you do not want any pictures taken of you or your name to be shown in any part of the Khorana Program: the website, brochures, orientation guides, power points etc.

Type name to certify

Date

Month

Day

Year

Health and Wellness Information

Please note: Study Abroad Programs do not require a physical for going abroad. However, it may be required for admission by certain universities or by certain countries/visas. We do recommend that you check with your physician for required/suggested immunizations as well as have a dental check-up before departure.

Are you generally in good physical condition? *

If no, please explain.

Have you ever been treated or are you currently being treated for any psychological or emotional problems? *

If yes, please explain.

Do you have any allergies? *

If yes, please explain.

Are you currently taking any medications? *

If yes, please explain.

Are you allergic to any medications? *

If yes, please explain.

Have you had any major injuries, diseases or ailments in the past 5 years? *

If yes, please explain.

Are you a vegetarian or are you on a restricted diet? *

If yes, please explain.

Is there any additional information (concerning medical conditions or physical disabilities) that would be helpful for the program to be aware of during your study abroad experience? *

If yes, please explain.

I certify *

I certify that all responses on this Medical Self-Assessment form are true and accurate, and I will notify the Khorana Program Administration of any relevant changes in my health that occur prior to the start of the program.

Type name to certify *

Date *

Month

Day

Year

Emergency Contact

Please provide three emergency contacts, with complete names, addresses and telephone numbers (day and night).

Contact 1

Name *

Address *

Relationship *

Day phone *

Evening phone *

Cell phone

Contact 2

Name *

Address *

Relationship *

Day phone *

Evening phone *

Cell phone

Contact 3

Name *

Address *

Relationship *

Day phone *

Evening phone *

Cell phone

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