APPLICATION FORM
2014-2015
Deadline: Friday, October 24, 2014 /
This program is for US citizens and US Permanent Residents (US Green Card Holders) only
NAME: ______
Last First Middle
CURRENT ADDRESS: ______
______
CELL PHONE NUMBER: _____-_____-______SCHOOL EMAIL: ______
PERSONAL EMAIL: ______
PERMANENT ADDRESS: ______
______
PERMANENT TELEPHONE NUMBER: _____-_____-______
UC ID: ______Are you a current NSF STEP Grant Recipient? ___Yes ___No
ENGINEERING MAJOR: ______
ANTICIPATED GRADUATION: ______CREDIT HOURS COMPLETED: ______
Month Year
CUMULATIVE GPA: ______on a 4.00 Basis.
Are you applying for Fall 2013 or Spring 2014 or both? ______
Please indicate if you intend to apply to a post-baccalaureate program after your undergraduate studies.
_____MS _____PhD _____MD ______Other
Have you had any prior research experience? _____Yes _____No
If Yes, indicate the Program (AY-REU/Summer REU/WISE/etc.), year, topic of the research, and name and affiliation of the faculty mentor: ______
______
Country of Citizenship (i.e., USA):______If not US Citizen, Visa Status: ______
NSF DIVERSITY REPORTING INFORMATION
The National Science Foundation requests such information simply to determine the diversity of students our program is attracting. It is strictly confidential and used only in aggregate form.
Gender: Male ___ Female ___
Do you have a disability? __ No ___ Yes (specify) ______
Race & Ethnicity:
White ___ Black or African American ___ Hispanic ______Latino ______
Native Hawaiian or Other Pacific Islander ___ Asian ___ Mixed Asian & White ___
Other Mixed Races ___ American Indian or Alaskan Native ___ No Race Reported ___
I do not wish to provide this information ______
REFERENCES
List names of two faculty members whom you have asked to submit a letter of recommendation in your behalf. Ask them to discuss your qualifications and suitability for a research assignment. The letters can be directly mailed by the referee to the address below, or must be included in a sealed and signed envelope by the applicant as part of the application process.
REFERENCE 1: REFERENCE 2:
NAME: ______NAME: ______
ADDRESS: ______ADDRESS: ______
______
TELEPHONE NUMBER: _____-_____-_____ TELEPHONE NUMBER: _____-_____-______
EMAIL: ______EMAIL: ______
Please list five research projects, in order of preference, on which you would like to work. Descriptions of the available research projects may be viewed at the web page for the NSF REU Program. Note that you must speak with or meet with the Project Advisor previous to applying to the project.
Project and Semester Project Advisor Date of Meeting with
Project Advisor
1. ______
2. ______
3. ______
4. ______
5. ______
I ATTEST THAT ALL INFORMATION SUBMITTED ON THIS APPLICATION IS ACCURATE.
______
SIGNATURE OF APPLICANT DATE
Please enclose the following:
(i) An essay of 500 (±50) words presenting your background, discussing your academic achievement, scholarships, work experience (if any), and biographical information, explaining why you are interested in this program and what you hope to gain from this experience.
(ii) Official transcripts.
(iii) Student Commitment Agreement
(iv) Student Course Schedule
(v) Two (2) Faculty recommendations including both:
· Faculty Recommendation Form, and
· Letter of Recommendation