Application: NEI Summer Research Program at Berkeley Optometry

	Complete form and email as an attachment to:
	Christine Wildsoet OD, PhD
	University of California - Berkeley
  	School of Optometry, Room 588 Minor Hall
	Berkeley, CA 94720-2020
	wildsoet@berkeley.edu 

Name:	     	

Address:	     	

Phone:	E-Mail:    	

US citizen:	Yes          No   	Permanent resident:	Yes            No   	

Pre-Optometry Institution:	     	Major:	   	

Optom School Institution:	     	Current GPA:	   	

Faculty members from your current and previous institutions who are willing to act as referees; list 3 with e-mail addresses

     	

     	

Previous research 
experience:	Yes            No 	 If yes, topic(s): 	     	

Current research 
activities:	Yes            No 	 If yes, topic(s): 	     	

Research fields of interests 
(complete if known):

Preferred mentor/s 
(complete if known):	     	

Resume (maximum 500 words): Include in your resume, your long-term career goals, any relevant research experience/skills, and how you expect to benefit from this program.