Personal Information
Last Name:	First Name:	Middle Name:
Gender: Male    Female
Email Address:
Current Mailing Address: Current Phone Number:
Permanent Home Address: Home Phone Number:
I am a(n): American citizen     Permanent resident
Ethnicity/Race: African American / Black, non-Hispanic American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Hispanic White, non-Hispanic

Educational Information
College or University that you are attending:
Major:	Minor:	Degree Expected:
GPA:     GPA in Major:     GPA Scale: A =
Expected Graduation Date:
Honors or Awards:
Special academic program you might be involved with (McNair, CSTEP, honorary fraternity, etc.):
Indicate areas of research you would like to pursue.
Principal research areas of interest: 1. 2. 3. 4.

References List below the names and titles of two faculty members (at your institution or elsewhere) whom you have asked to write letters of support for your application. These persons should be familiar with your academic and/or research abilities and should be able to judge whether you are suited for undergraduate chemical research.
Faculty Member #1
Name:
Title:
Email Address:
Telephone Number:
Faculty Member #2
Name:
Title:
Email Address:
Telephone Number:

Personal Statement Please provide a brief statement (one page) describing your career goals in scientific research and why you wish to participate in this program. Specifically discuss your plans after your undergraduate graduation (graduate school, employment, etc.) and why you wish to pursue this research opportunity and discuss all prior research activities.

Form Submission

I understand that in accepting participation, I commit myself to be available from June 7 through August 13, 2010. I shall arrange all personal and academic obligations to adjust to this schedule. Check here to acknowledge this statement. We recommend printing this form for your records before submitting it.