APPLICATION FORM

National Science Foundation

IRES in China -Advanced Materials for a Sustainable Development

Statement of Confidentiality: The information contained in this application is for the purpose of determining the applicant’s eligibility for the Summer Research Program. Information received is treated confidentially. Application Window: December 7, 2012 ~ January 31, 2013.

Respond to all questions in each section on both pages (please type or print in ink)

NAME: ______

Last First Middle

Social Security Number: ______E-mail Address:______

Mailing Address: ______Home Address:______

______

City State Zip Code City State Zip Code

______

Telephone Number Telephone Number

Citizenship: U.S. Citizen Permanent Resident Other ______

If Permanent Resident, give alien registration number: ______

Date of Issue: ______

The following voluntary information is used for statistical purposes:

Sex: F M Birth Date: ______Place of Birth: ______

Ethnic Group:

American Indian / Alaskian Native Asian / Asian American

African American Hispanic/ Hispanic American

White / Non-Hispanic Other (please specify)______

College or University Education. Provide official transcripts from each institution attended.

Institution / Location / Field of Study / Dates Attended / # of Credits Earned
_____ to _____
_____ to _____
_____ to _____

Degree Objective:______

Degree Major Field

Cumulative GPA: ______out of possible ______Expected date of graduation: ______

Professional or work experience:

Dates / Employer / Location / Nature of Position

Are you planning to go to graduate school? Yes No Maybe

Brief description of your laboratory and computer skills, if any

Matlab / Fortran / C++ / Lab (specify)

Academic honors, prizes, or scholarships you have received or honor societies to which you have been elected:

______

List extracurricular activities you have been involved in:

______

Review the list of research projects proposed for this year’s summer program (viewable on the web at the same website). Indicate three projects that are most interesting to you:

1.______

2.______

3.______

Names of references and contact information:

1.______

2. ______

I certify that the statements made in this application are true to the best of my knowledge. If admitted, I agree to abide by the rules and regulations of Clarkson University and the National Science Foundation International Research Experience for Students in China on Advanced Materials for Sustainable Development. I understand that knowingly giving false information may result in my dismissal from the application process and the Program.

Signature of applicant:______Date:______

Other required materials:

·  Two letters of recommendation.

·  Official transcript.

·  Statement of interest.

Note: This application and all correspondence concerning it should be sent to Dr. Hayley Shen,

Clarkson University, Department of Civil and Environmental Engineering, Potsdam, NY 13699-5710

Email:

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EDUCATIONAL INSTITUTION