Form 6 Amgen-Supplemental Application

AMGEN SCHOLARS PROGRAM AT NIH ‐SUPPLEMENTAL APPLICATION
OMB Clearance Number: 0925-0299
Expiration Date: 30-Jun-2019

CONTACT INFORMATION
Enter your NIH Summer Internship Program Application Number:*

First Name (Given Name):*

Last Name (Family Name):*

Email Address Used in SIP Application:*

ADDITIONAL ACADEMIC INFORMATION
High School City:*

High School State:*

Year of Expected Graduation from your Undergraduate College/University:*

What is your ultimate Degree Objective? *

HOW DID YOU HEAR ABOUT THE AMGEN SCHOLARS PROGRAM?
Amgen National Web Site:*

Academic Advisor:*

Email:*

Faculty/Staff from Home University:*

Internet Search:*

Poster:*

Conference:*

Faculty/Staff from Other University:*

University Web Site:*

Other:*

RESEARCH EXPERIENCE
Are you applying to other Amgen Sites?*

Have you participated as an Amgen Scholar in the past?*

Have you participated in the NIH Summer Internship Program in the past, either as an
intern or as a volunteer?*

Have you participated in research as an undergraduate (academic year or summer)?*

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights
of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties
for not participating or withdrawing from the study at any time. The information collected in this study will
be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the
study. Information provided will be combined for all participants and reported as summaries.