Student Research

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Honors in Research Application Form

Student Honors in Research Program Transmittal Form

Attached documents (circle):

Research Proposal

Final Report

Applying as (circle):

Please type or print:

First name:

Middle name:

Last name:

Applicant Daytime Telephone Number, including area code:

Faculty Advisor:

Phone Number, including area code:

Other Collaborators:

Applicants entering as D3 students are required to apply by October 1. Final Report should be submitted by January 1st of the D4 year to be acknowledged at commencement.

ASSURANCES

Indicate whether or not your research involves any of the following areas of institutional assurance (circle):

ANIMAL RESEARCH

HUMAN SUBJECTS RESEARCH

BIOHAZARDS RADIOACTIVE/LASER

Do any investigators involved in this project have an actual, real, or perceived conflict of interest as identified in the conflict of interest policy? (circle)

Yes

Signature and Date:

Student:

Date:

Faculty Advisor:

Date:

Associate Dean for Research:

Date:

Dean, School of Dentistry

Date:

Please return this application to:

The University of Mississippi Medical Center, School of Dentistry, Office of Research (D528-6A)

2500 North State Street , Jackson, MS 39216-4505 PHONE: (601) 984-6010 FAX: (601) 984-6087