2011 On-line Application Form

Personal Information

 
Title:
 
Last name:
 
First Name:
 
Middle Initial:
 
E-Mail Address:
 
Re-enter to confirm your E-mail:
Current Address at School:
 
Street or dormitory:
 
City:
 
State:
 
ZIP:
 
Contact Phone (include area code):
Home (Permanent) Address:
 
Home Address:
 
City:
 
State:
 
ZIP:
 
Home Phone (include area code):

College/University Information
[You must attend a U.S. institution to participate in this program.]

College or University currently attending:
 
Other Universities attended:
 
Academic classification at the
beginning of Fall Term 2010:
 
Degree seeking :
 
Major:
 
If 'other' please enter major here:
 
Minor:
 
If 'other' please enter minor here:
 
Expected date of graduation:
  Your summer availability in 2010 (format MUST be MM/DD/YYYY)
 
From:
 
Until:

You may cut and paste from a word processing document into the fields below if the information
is plain text only (no special characters or graphics)
.
If you encounter an error submitting this
application, these fields are the most likely source of problem.

Please give us a statement of reasons why you would like to participate in this program:

Please list any awards, honors or other notable accomplishments:

Please list publications, if any:


Have you had any experience in a science research program?
 
If 'yes,' please give type and description of the research:
 
  Please indicate your top two choices of research fields.
 
First choice:
 
Second choice:
  Please indicate your preference for host laboratory (for a list of labs and research topics, click here)
 
First choice
 
Second choice

 
Third choice

     
 

Academic Information

  Please give course name, credit hours granted and grade received for each course listed below.
Once you have successfully submitted this form, you will receive information on where to mail a copy (unofficial is ok) of your transcripts.
 
Chemistry lecture courses:
 
Chemistry laboratory courses:
 
Other science courses:
 
Math courses:
 
 
 
Overall GPA:
 
Are you planning to attend graduate school?
 
If yes, please choose one of the following interest areas:
 

 

 
  To help the project comply with our commitment to the National Science Foundation, we urge to identify your demographic data. You may decline to do so without prejudicing the action taken on your application.
 
Gender:
 
Race:
 
Ethnicity:
 
Disability:
 
Citizenship:
     
 

References

 
  Two references are required. It is your responsibility to contact your references and request that they endorse your application.
 

Waiver:

By checking yes below, I expressly waive any rights I might have to access this recommendation under the Family Educational Rights and Privacy Act of 1974, or any other law, regulation or policy. I understand that I am not required to execute this waiver and my application will be reviewed whether or not I check to waive my rights.

 
Reference #1:
 
 
Title:
 
First Name:
 
Last Name:
 
Affiliation:
 
City:
 
State:
 
Telephone (include area code):
 
FAX (include area code):
 
E-mail:
 
Reference #2:
 
 
Title:
 
First Name:
 
Last Name:
 
Affiliation:
 
City:
 
State:
 
Telephone (include area code):
 
FAX (include area code):
 
E-mail:
     
 
How did you hear about this program?:










 


Important! Please review your application now.

Do NOT press the 'Submit' button until the form has been COMPLETELY filled out.