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Application for
NASA Research Center for Bio-nanotechnology and Environmental Research
C-BER. Collaborative Training Program
Submit Application to
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Brandi Butler
NASA URC- Administrative Assistant
Room 203U/New Science Bldg.
Texas Southern University
3100 Cleburne Street
Houston, Texas 77004
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Date: ___ / ___ / _______
CITIZENSHIP: Yes or No
Name
Last Name: __________________________________________________________
First name: __________________________________________________________
Middle Name: ________________________________________________________
Other: __________________________________________________________
Contact Information
E-mail address:
Current Mailing Address: _________________________________________________________
Street________________________________________________ ___________ _______________
City State Zip Code
Current Phone Numbers: ____________________________ _____________________________
Home Cell or Other
Permanent (if different from above)
Mailing Address: __________________________________________________________
Street_____________________________________________________________________
City _____________________ State _________ Zip Code __________________
Permanent Phone Number: ____________________________ ____________________________
Home Cell or Other
Personal Information
Date of Birth: _______________ Birth Place: _____________________________ ___________
City state
___ Black-non-Hispanic ___ Hispanic
___ White-non-Hispanic ___ Native American
___ Asian or Pacific Islander
For Non-US Citizen & Non-Perm. Resident
Visa type _____
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Residency: _______________ _________
State country
Gender: Ethnic Origin:
Education
Beginning with High School and proceeding to current date, list institutions of education, state in which located, date of attendance, the subject major for post-secondary education, and outcome (degree and/or honor earned).
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School and location
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Subject major
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Dates attended
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Outcome
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Please complete the table below for those course(s) which you have completed.
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Course Topic
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Course number(s) and credit hours
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Year
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Grade
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Biology
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Organic Chemistry
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Calculus
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Participation in other Programs
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Agency
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Location
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Dates
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Outcome
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No Yes If yes, please sp:
Other than minor traffic violations, have you ever been convicted of a felony or misdemeanor?
No Yes If yes, please explain:
By my signature below, I certify that the information on this form is true and correct to the best of my knowledge. I understand that willfully withholding information or making false statements in this application may be used as the basis for denial of admission or for dismissal from this Program.
_____________________________________________ ________________________
Signature Date
_____________________________________________________________________________________________________________________________________________
NASA Research Center for Bio-nanotechnology and Environmental Research
Undergraduate Collaborative Training Program
Letter of Recommendation
Applicant: Complete this part of the form and give to the recommender with an envelop with your name and the title of this Program typed in place of the address. Arrange for the Recommender to contact you to pick up this form in the sealed envelope with Recommender’s signature across the seal.
Applicant Information
Name: ______________________________ ______________________ _________________
Last First Middle
Contact information: ___________________________________________________________
I understand that federal legislation provides me with a right of access to this recommendation; while this right may be waived, no school or person can require me to waive this right.
Check one of the following statements: ____ I hereby WAIVE my right of access to this recommendation.
____ I do NOT waive my right of access to this recommendation.
__________________________________________________ __________________________
Signature Date
Name of Recommender: _________________________________________________
Applicant: Do not write below this line.
Recommender: If the Applicant waives his/her right to access this recommendation (as indicated above by the applicant), then this recommendation will be held in confidence from the applicant.
Please complete the form, which continues on the back. You may use a separate page(s) for your statement, as you deem necessary. Place this form in a sealed envelope and sign across the seal. Contact the student as directed above to arrange for the student to pick up this recommendation to add to his/her application packet.
In what capacity do you know the Applicant? ______________________________________________
___________________________________________________________________________________
How long have you known the Applicant? ________________________________________________
On a scale of 1 to 5 with 5 being outstanding, how would you score this applicant in terms of:
__ Scholastic ability ___Science/Mathematics aptitude ___Suitability for training in research
_______________________________________ _____________________________________
Signature Institution
_______________________________________ _____________________________________
Name (type or print) Address
_______________________________________ _____________________________________
Position or Title Daytime phone or e-mail address
Recommender: In addition to the information that you provided on the front of this form, please evaluate the applicant’s outstanding strengths and weaknesses, using specific examples where appropriate. Also address the applicant’s motivation and potential to pursue a career in the STEM areas. Include any other information about the applicant that you believe could be pertinent to the applicant being selected for this Program. You may use the space below or attach another page.
_____________________________________________________________________________________________________________________________
NASA Research Center for Bio-nanotechnology and Environmental Research
Undergraduate Collaborative Training Program
Letter of Recommendation
Applicant: Complete this part of the form and give to the recommender with an envelop with your name and the title of this Program typed in place of the address. Arrange for the Recommender to contact you to pick up this form in the sealed envelope with Recommender’s signature across the seal.
Applicant Information
Name: ______________________________ ______________________ _________________
Last First Middle
Contact information: ___________________________________________________________
I understand that federal legislation provides me with a right of access to this recommendation; while this right may be waived, no school or person can require me to waive this right.
Check one of the following statements: ____ I hereby WAIVE my right of access to this recommendation.
____ I do NOT waive my right of access to this recommendation.
__________________________________________________ __________________________
Signature Date
Name of Recommender: _________________________________________________
Applicant: Do not write below this line.
Recommender: If the Applicant waives his/her right to access this recommendation (as indicated above by the applicant), then this recommendation will be held in confidence from the applicant.
Please complete the form, which continues on the back. You may use a separate page(s) for your statement, as you deem necessary. Place this form in a sealed envelope and sign across the seal. Contact the student as directed above to arrange for the student to pick up this recommendation to add to his/her application packet.
In what capacity do you know the Applicant? ______________________________________________
___________________________________________________________________________________
How long have you known the Applicant? ________________________________________________
On a scale of 1 to 5 with 5 being outstanding, how would you score this applicant in terms of:
__ Scholastic ability ___Science/Mathematics aptitude ___Suitability for training in research
_______________________________________ _____________________________________
Signature Institution
_______________________________________ _____________________________________
Name (type or print) Address
_______________________________________ _____________________________________
Position or Title Daytime phone or e-mail address
Recommender: In addition to the information that you provided on the front of this form, please evaluate the applicant’s outstanding strengths and weaknesses, using specific examples where appropriate. Also address the applicant’s motivation and potential to pursue a career in the STEM areas. Include any other information about the applicant that you believe could be pertinent to the applicant being selected for this Program. You may use the space below or attach another page.
_____________________________________________________________________________________________________________________________________________
NASA Research Center for Bio-nanotechnology and Environmental Research
Undergraduate Collaborative Training Program
Personal Statement
Please attach your transcript from Texas Southern University. (You may attach transcripts from other colleges and universities if you believe that it strengthens your application.)
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