Submit electrronically this application and a brief outline fo the proposed Honors Program research plan (described separately on this web site) to:

Dr. Michael G. Levitzky
(mlevit@lsuhsc.edu)
Department of Physiology
Box P7-3, MEB
1901 Perdido St.
New Orleans, LA  70112

Name: ____________________________________________   Date: _____________________

Home Address: ________________________________________________________________

                        City: ___________________________  State: _________  Zip:_______________

                        Home phone number:   (       )                                                                                   

LSU Box number: ______  Local phone number: ______________  Email address______________

High School Attended:   Name-_____________________________________________________

                        City: ___________________________  State: _________  Zip:_______________

College Attended: Name-_________________________________________________________

                        City: ___________________________  State: _________  Zip:_______________

                        Honors: __________________________________________________________

                        Grade Average: ____________  Grading System__________________

Did you conduct any research or special projects? ___________
        (If so, please describe the work on a separate sheet of paper)

Grades in courses taken thus far:     Gross Anatomy__________                                            Biochemistry___________

                                                   Cell Biology ____________                                                Neuroscience _________

                                                  Science and Practice of Medicine __________________     Physiology ____________

Area(s) of interest in medicine, if known: ______________________________________________

Brief statement of major reason for interest in applying to the Honors Program:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________