DEPARTMENT OF BIOCHEMISTRY AND MOLECULAR BIOLOGY
SCHOOL OF GRADUATE STUDIES
LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
SHREVEPORT, LOUISIANA
Preliminary Application for Graduate Study
NAME: ___________________________________________ Desired start date: ____________________________
(quarter/year)
PERSONAL DATA:
Present mailing address: _________________________________________________________________________
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Telephone numbers:
Work: (_____) ___________
Home: (_____) ___________
Permanent: (_____) ___________
E-mail address: _________________________________________________________________________________
Date and place of birth: ___________________________________________________________________________
Citizenship: _____________________________
(If not US) current Visa status: ________________________
GRE Test Date: ______ ______ GRE scores: V. _______ ________ Q. _______ ________ A. _______ ________
month year
% below
% below
% below
GRE subject test: _________ _________ Test name: _______________________________ ________ ___________
month
year
Score
% below
If you are a Foreign Student and English is not your primary language, have you taken the Tests of English as a Foreign
Language (TOEFL)
___ Yes
What was your score? ___________
___ No When will you take it? _________
COLLEGES AND UNIVERSITIES ATTENDED:
Name of Institution
Major
GPA
Dates
Degree
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EMPLOYMENT RECORD:
Names and Addresses of
Recent Employers
Title/Duties
Dates
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1 List names and addresses of three persons asked to write letters of reference.
Name
Mailing Address
Email Address
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STATEMENT OF GOALS: List a statement of your academic and professional goals, and describe your
reasons for selecting a graduate program in Biochemistry and Molecular Biology.
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COURSES: List courses in biology, biochemistry, chemistry and other science and mathematics areas that you have
taken.
Course
Title
Course No.
Credits
Grade
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LABORATORY EXPERIENCE: List any research experience you have had, including any publications.
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HONORS: List academic honors, scholarships, etc., giving awarding institution and dates:
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_________________________________________________________________________________________________ 2 OTHER: List any teaching experience or other things about yourself not covered above.
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Certificate
I certify that to the best of my knowledge, the information given on this application is correct and complete. I understand
that if it is later found out to be otherwise, my application may be rejected, or in the event that I am enrolled, I may be
subject to dismissal from the University.
______________________
Date
__________________________________
Signature
Email completed form to: Dr. Stephan N. Witt
Professor and Interim Head
Department of Biochemistry and Molecular Biology
Email: [email protected]
Or
Mail to:
Dr. Stephan N. Witt
Professor and Interim Head
Department of Biochemistry and Molecular Biology
LSU Health Sciences Center - Shreveport
1501 Kings Highway
Shreveport, LA 71103
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