Collegiate Science and Technology Entry Program

Winter Internship Program Application

Please Print or Type (All the fields are required)

Application for:
Winter Internship (1/4/2016 to 1/15/2016) (Monday to Friday 9am to 5pm)

Last Name  First Name Middle Name

Present Address  Apt

City State Zip Code

Telephone E-Mail  


Permanent Address (If Different)    Apt

City State Zip Code

Telephone E-Mail  

Legal State of Residence  

Country of birth, if other than USA: 

If permanent registered alien, Registration #

Date of Birth

Sex: Male Female

Ethnicity: Asian/Pacific Islander African-American/Black White/Caucasian

Hispanic/Latino Native-American Indian/Alaskan Other Two or more Races



School Currently Attending

Class Level Expected Date of Graduation

Major Intended Career 

Pre-Professional Program of Study

(i.e.: Pre-Med, Pre-Dental, Pre-Optometry, etc.)

Overall GPA   Science GPA Math GPA  

SAT Scores: Verbal Math Writing


Parental Information:

Father's Name

Mother's Name  

Total Annual Family Income

Sources of Income

Number of Members in Household


Have you ever participated in any of the following State-sponsored programs?

STEP CSTEP HEOP EOP SEEK College Discovery Other (Name)

If you participate in any of the above programs at your school, please give:

Director or Coordinator's Name 


NOTE: Being a member of CSTEP at another College does not preclude you from participating in SUNY Optometry's CSTEP Internship Program.

Have you ever had your eyes examined by an optometrist? Yes No

Have you ever spoken to an optometrist about his/her profession? Yes No

In 500 words or less, please write an essay answering the following question:

From what you already know about optometry and have read in our CSTEP brochure, please explain how the CSTEP Internship and/or Summer Academic Program will benefit you in your professional pursuits?


Additional Documents Needed:

1. Current College Transcript (unofficial transcript is acceptable)(including up to Summer 2015 Grade Reports)
2. Current class schedule or course registration.
3. Signed Letter of Recommendation (from a Professor, Supervisor, Counselor, or other non-family member who can speak to your character and potential success in our program).
4. Economically disadvantaged applicants only: if you have not participated in other CSTEP or New York State-sponsored programs, please submit documents verifying household income (i.e.: 2014 IRS 1040 forms).

Please email or fax additional documents to Carlos Restrepo: or (fax) 212-938-5504. Letter of recommendations may be emailed or faxed directly to Carlos Restrepo as well.

 Your application will be INCOMPLETE and NOT REVIEWED until ALL additional documents are received.

 Admission is rolling. Application Deadline: December 1, 2015