First Name:

Last Name:

PU Identification Number:

Address:

City: State: Zip:

Country:

Daytime Phone: Evening Phone:

E-mail Address:

Academic classification at the beginning of fall term 2008:

Expected Date of Graduation:

Degree (B.A. or B.S.):

Answer the following questions with a short description.

Career or Educational Plans after Graduation:

Honors or Awards:

Have you any experience in a science research program?

Yes No

If yes, please give type and description of the research?:

How do you expect to benefit from participation in the Indiana-LSAMP Summer 2008 Undergraduate Research Fellowship Program?:

How do you anticipate that participation in this program will help you achieve your career goals?:

Please indicate your choice of research advisor:

Please indicate your area of research [science, technology, engineering, or mathematics].:

Request a letter of support from two individuals who are familiar with your accomplishments and potential for professional success. One of these letters should be from the person you have requested as your research advisor. Please use the Indiana-LSAMP reference letter forms. Indicate the names and addresses of your references below.

References were requested from:

Place a check in the box if you agree with the statement

I agree to participate in at least three LSAMP activities during the semester

I agree to write a contract for the research to be done with my mentor

I agree to give an oral presentation or poster presentation at the Research Day

I agree to attend the Indiana LSAMP Conference in the fall

To the best of my knowledge, all of the above information is correct. I authorize Purdue University Calumet to release required information such as social security, name and other personally identifiable information solely for the purposes of participation in the NSF - LSAMP grant program.

The following information is optional and its omission will in no way jeopardize consideration of your application. Please check all categories that are appropriate.

Gender: Male Female

Ethnicity: Black, not of Hispanic Origin American Indian or Alaskan Native Hispanic Pacific Islander Asian