Applicant's U.
S. Residency
Status:
U. S. Citizen
U. S. National
U. S. Permanent Resident (Green Card)
Student Visa
Other
Applicant's First Name:
MI:
Last Name:
University ID Number (UIN):
Phone Number:
Email Address:
Mailing Address:
City: State: Zip Code:
Texas
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D. C.
West Virginia
Wisconsin
Wyoming
Activities and Awards
Complete each of the following (for as
many as apply):
1.
List college activities (including student government, sports,
school publications, student-faculty committees, arts, musical
endeavors, etc.).
List those that are most significant to you first.
Name of Activity
Office Held
Date
a.
b.
c.
d.
e.
f.
2.
List public service and community activities since your high
school graduation (include projects, environmental protection
and conservation efforts, advocacy activities, volunteer work
for non-profit, and/or work with religious organizations, as
applicable). Do not repeat items listed previously.
Activity and Description of Role
Date
a.
b.
c.
d.
e.
3.
List part-time and full time jobs and/or internships (paid or
non-paid) since your high school graduation.
Job
Title
Date
Paid?
a.
b.
c.
d.
e.
f.
4.
List awards, scholarships, or special recognitions you
have received while in college. Do not repeat items listed
elsewhere.
Awards and Sponsoring Organizations
Date
a.
b.
c.
d.
e.
f.
5.
What do you expect to contribute as a STEM Fellow, and how do
you expect to benefit ?
