Siddharth Mohan, Biomedical Engineering Ph.D.
,, Fall 2015
HORACE H. RACKHAM SCHOOL OF GRADUATE STUDIES
UNIVERSITY OF MICHIGAN
Application Form - Page 1
Acknowledgement
I certify that all information in this application is true and complete, and that I am the author of
my Academic Statement of Purpose and Personal Statement. I understand that the University
and credentials may result in the withdrawal of my application or in the revocation of admission,
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University of Michigan.
Personal Information
First (Given)
Siddharth
Last (Family)
Mohan
No
If currently in the United States, Visa type:
SEVIS ID Number:
Other name that appears on prior academic records or test score
reports
Other First Name
Other Last Name
Name of the institution/organization that issued the I-20 or DS-2019
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Please indicate whether you consider yourself to be Hispanic or Latino.
Yes, Hispanic or Latino
No, not Hispanic or Latino
Male
Birthdate (month/day/year)
Birthplace City
Jaipur
State/Province
Rajasthan
Country
Visa Information (Non-U.S. Citizens only)
U.S. Visa type you plan to use or obtain F1
Will you have dependents accompanying you to Michigan?
Middle
Gender
Parent #2 was a citizen or a permanent resident of the U.S. at the time I
was born.
07-08-1992
In addition, select one or more of the following racial categories to describe yourself:
American Indian or Alaska Native
Asian
Black or African American
White
India
Native Language
Malayalam
Previous Enrollment
If you have an 8 digit University of Michigan ID Number, Please
enter it here:
Have you ever taken a class at the University of Michigan - Ann Arbor
Campus? No
Are you applying to the Concurrent Undergraduate/Graduate Studies
(CUGS) program?
Have you ever registered for a Rackham class as a Rackham student?
U.S. Military Service
On active duty U.S. military
Veteran of U.S. armed forces
U.S. Reserves or National Guard
U.S. Military Dependent
Parents Education Information
Parent #1 highest educational level completed Graduate or professional degree
(ex.: M.A., Ph.D., M.B.A. or J.D.)
Parent #2 highest educational level completed Graduate or professional degree
(ex.: M.A., Ph.D., M.B.A. or J.D.)
Are you currently registered in a Rackham program as a Rackham
non-degree/guest student?
Are you currently registered in a Rackham Program as a Rackham
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Intended Graduate Program
Biomedical Engineering Ph.D.
Subplan
Do you intend to complete this program?
If you have a Uniqname issued by the University of Michigan, please
enter it here:
@umich.edu
Proposed Term/Year of Enrollment
Fall 2015
Applying to more than one Rackham Program
United States Social Security Number
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Source of Fee Waiver
Rackham program 2
Fee Waiver Code
Citizenship Status
Graduate Program Information
Rackham program 3
Non-U.S. Citizen
Country of Citizenship India
(Permanent Residents and Non-U.S. Citizens Only)
Applying to Dual Degree
U.S. Permanent Resident Registration Number A
Are you applying to a dual degree program with a non-Rackham school or
college? No
For U.S. Citizens and Permanent Residents only
Parent #1 was a citizen or a permanent resident of the U.S. at the time I
was born.
School or College
Online Application 2014-2015
Siddharth Mohan, Biomedical Engineering Ph.D.,, Fall 2015
HORACE H. RACKHAM SCHOOL OF GRADUATE STUDIES
UNIVERSITY OF MICHIGAN
Application Form - Page 2
CURRENT Address Information
Address Line 1 E-19, Mahawat
Address Line 2
City
Behind Rouse Avenue
New Delhi
Country
State/Province
Delhi
U.S. Zip/International Postal Code
91
or Pass/Fail
International Average
Ext.
State/Province
Major Field
Major Field
Degree/Diploma
Road,Railway Qtr
Level of Education
Behind Rouse Avenue
New Delhi
State/Province
Delhi
India
U.S. Zip/International Postal Code
to
Country
91-9717639950
PERMANENT Address Information
Address Line 1 E-19, Mahawat Khan
Country
on a scale of
Location City
Home Phone 91-11-23233130 Work Phone
City
GPA
Dates Attended
X
Current until
E-mail [email protected]
Address Line 2
Degree Status
Institution 3
India
Cell Phone
Degree Date
Khan Road,Railway Qtr
91
Degree Date
Degree Status
GPA
on a scale of
or Pass/Fail
International Average
Institution 4
Phone
Michigan Residency
Residency
Michigan Resident, since
X Non-Michigan Resident
Dates Attended
Education Information
Country
to
Location City
000000628
Birla Institute of Technology and Science Pilani
07-2014
Dates Attended 08-2010
to
State/Province
Bachelor Degree Institution
Location City
Country
Pilani
State/Province
RJ
India
Major Field
Major Field
Bachelor of Engineering
Level of Education
Degree Date
Major Field
Degree/Diploma
Level of Education
Mech Engin - Other
Degree/Diploma
Major Field
Bachelor's
07-2014
Degree Date
Degree Status
GPA
on a scale of
or Pass/Fail
International Average
Institution 5
Degree Status
Completed
Dates Attended
GPA
on a scale of
or Pass/Fail
International Average
9.04/10
Location City
to
State/Province
Country
Institution 2
Major Field
Dates Attended
Location City
to
Major Field
State/Province
Degree/Diploma
Country
Level of Education
Major Field
Degree Date
Degree Status
Major Field
GPA
on a scale of
Degree/Diploma
or Pass/Fail
International Average
Level of Education
Online Application 2014-2015
Siddharth Mohan, Biomedical Engineering Ph.D.,, Fall 2015
Application Form - Page 3
HORACE H. RACKHAM SCHOOL OF GRADUATE STUDIES
UNIVERSITY OF MICHIGAN
For U.S. Citizens and Permanent Residents only
Additional College or University Information
Indicate whether you received or will receive a degree from any of the
following institutions in the U.S.: (select all that apply)
Language 5
Native speaker?
Community or Junior College
Historically Black College or University
Predominantly Latino or Latina-Serving College or University
Single-Gender College
Tribal School or College
None of the above
Able to translate?
Speaking
Writing
Years of study in high school
Terms of study in college
Language 1
Additional experience
English
Native speaker?
Yes
Able to translate?
Yes
High
High
Speaking
High
Years of study in high school
Terms of study in college
Writing
High
throughout
Language 6
Native speaker?
Able to translate?
Speaking
English
Writing
Years of study in high school
Additional experience
Terms of study in college
Language 2
Additional experience
Native speaker?
Able to translate?
Speaking
Writing
Years of study in high school
Awards/ Scholarships Information
Awards/ Scholarships 1
Institution
Terms of study in college
Awards/ Scholarships 2
Language 3
Institution
Native speaker?
Open Competition
Dates or Academic Year
Additional experience
Able to translate?
DAAD WISE Scholarship
05-2013
Vamsikrishna Pendyala Memorial
BITS-Pilani
Dates or Academic Year
05-2012
Speaking
Writing
Activities Information
Since graduating from high school, have you pursued any volunteer activities, work experiences, or leadership of student organizations that were
based on race, ethnicity or gender, or to improving race relations in the
U.S.?
X
! "## $%
Years of study in high school
Terms of study in college
Additional experience
Language 4
Native speaker?
Able to translate?
Speaking
Writing
Years of study in high school
Terms of study in college
Additional experience
Online Application 2014-2015
Siddharth Mohan, Biomedical Engineering Ph.D.,, Fall 2015
Application Form - Page 4
HORACE H. RACKHAM SCHOOL OF GRADUATE STUDIES
UNIVERSITY OF MICHIGAN
For U.S. Citizens and Permanent Residents only:
If you attended a U.S. college or university, indicate whether you have
participated in any of the following programs that encourage students to
pursue graduate education: (select all that apply)
Bridges to the Baccalaureate
Committee on Institutional Cooperation: Summer Research
Opportunity Program (CIC SROP)
Gates Millennium Scholars Program
Graduate Engineering and Science Fellowships for Minorities (GEM)
Institute for Recruitment of Teachers (IRT)
Louis Stokes Alliance for Minority Participation (LSAMP)
Mellon Mays Undergraduate Fellowship
Minority Access to Research Careers (MARC)
Post-baccalaureate Research Education Program (PREP)
Project 1000
Ralph Bunche Summer Institute
Ronald E. McNair Post-Baccalaureate Achievement Program
Public Policy and International Affairs Program (PPIA)
Western/National Name Exchange (NNE)
None of the above
Financial Assistance Information
1. During your undergraduate study, did you receive a Pell Grant from
the U.S. Government? (For U.S. Citizens and Permanent Residents
only)
Yes
No
2. While you were an undergraduate student, did you work to pay at least
some of the cost of your undergraduate tuition, books and housing?
(Do not include work you did to pay for other expenses such as meals,
transportation or entertainment.)
Yes X No
!
for the total cost of your undergraduate education (tuition, housing,
books)?
1 = little/none
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%&&
Employment/Work Experience Information
Name of Employer 1
Position/Title
City
Research Intern
Dresden
Country
Name of Employer 2
Position/Title
Dates: from
to
07-2013
Research Intern
State/Province
TX, Texas
Other Information
If you are applying to other graduate institutions at this time, please indicate which one(s) here
Stanford
Caltech
United States
Cornell
Current Employee
Name of Employer 3
Position/Title
Dates: from
01-2014
to
07-2014
Supreet Singh Bahga,IIT Delhi
Research Intern
New Delhi
Country
05-2013
Siva Vanapalli, Texas Tech Uni
Lubbock
Country
City
State/Province
Germany
Current Employee
City
Andreas Richter,TU Dresden
State/Province
Delhi
India
Optional
I give permission to the following person to contact the graduate program
on my behalf during the application process: (optional)
First Name, Last Name
X Current Employee Dates: from 10-2014 to 06-2015
Relationship
Name of Employer 4
Position/Title
City
State/Province
Country
Current Employee
Dates: from
to
Online Application 2014-2015
Smita Paul
father's sister
Siddharth Mohan, Biomedical Engineering Ph.D.,, Fall 2015
HORACE H. RACKHAM SCHOOL OF GRADUATE STUDIES
UNIVERSITY OF MICHIGAN
Recommendations
Country India
Recommender 1
First Name Siva
Vanapalli
Last Name
Associate Professor
Title
Phone
+91-1596-515664
E-Mail
[email protected]
Do you waive the right to view the recommendation?
Institution/Company
Address, line 1
Texas Tech Univesity
Dept of Chemical Engineering ,TTU,Lubbock-79409-3121
Use online recommendation system?
Yes
Recommender 4
First Name
Address, line 2
Lubbock
City
TX
State
Country
Postal Code
Last Name
79409
Title
United States
Institution/Company
Phone
001-806-7421757
E-Mail
[email protected]
Address, line 1
Address, line 2
Do you waive the right to view the recommendation?
Use online recommendation system?
Yes
City
Yes
State
Postal Code
Country
Recommender 2
First Name Niti Nipun
Phone
Sharma
Last Name
E-Mail
Professor
Title
Do you waive the right to view the recommendation?
Institution/Company
BITS Pilani,India
Address, line 1 Mechanical Engineering Dept,BITS Pilani,Pilani
Address, line 2
Rajasthan,India -333031
Additional Information
Pilani
City
Rajasthan
State
Country
Use online recommendation system?
Postal Code
333031
India
Phone
+91-1596-245073
E-Mail
[email protected]
Do you waive the right to view the recommendation?
Use online recommendation system?
Yes
Yes
Recommender 3
First Name Dipendu
Last Name
Bhunia
Assistant Professor
Title
Institution/Company
BITS Pilani,India
Address, line 1
Civil Engineering Dept,BITS Pilani,Pilani
Address, line 2
Rajasthan,India -333031
City
Pilani
State
Rajasthan
Postal Code
Online Application 2014-2015
Yes
Siddharth Mohan, Biomedical Engineering Ph.D.,, Fall 2015
Biomedical Engineering
Description of Interests Form
In addition to including the following information
in your Statement of Purpose, please complete
the following.
Research Interests
Please select and rank your top three
research interests.
Bio-Micro/Nanotechnology and Molecular Engineering
Tissue Engineering and Biomaterials
Biomechanics
Faculty Members
faculty with
whom you are interested in working.
1. Nikolaos Chronis
2. Xudong Fan
3. Joseph Bull
4. Mark Burns
Michael Meyer
HORACE H. RACKHAM SCHOOL OF GRADUATE STUDIES
UNIVERSITY OF MICHIGAN
